GENERAL FUND MRDD & JOB AND FAMILY SERVICES EMPLOYEES County... · 6/12/2011 · Effective: October 1, 2010 Restated: January 1, 2012 . Perry County 2 Employee Health Plan – General

Perry County

Employee Health Plan – General Fund, MRDD & Job and Family Services Employees

Plan Document and Summary Plan Description

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PPO - NON-GRANDFATHERED

PERRY COUNTY EMPLOYEE HEALTH PLAN

GENERAL FUND

MRDD & JOB AND FAMILY SERVICES EMPLOYEES


Effective: October 1, 2010

Restated: January 1, 2012

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TABLE OF CONTENTS

Page

ARTICLE I ESTABLISHMENT OF THE PLAN; ADOPTION OF THE PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION.......................................................................................................................... 3

ARTICLE II INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION ................................... 4

ARTICLE III SUMMARY OF BENEFITS .............................................................................................................. 6

ARTICLE IV DEFINITIONS................................................................................................................................... 12

ARTICLE V ELIGIBILITY FOR COVERAGE SPECIAL RESTRICTIONS FOR PRE-EXISTING

CONDITIONS ........................................................................................................................................................... 28

ARTICLE VI TERMINATION OF COVERAGE ................................................................................................. 35

ARTICLE VII CONTINUATION OF COVERAGE ............................................................................................. 36

ARTICLE VIII GENERAL LIMITATIONS AND EXCLUSIONS ...................................................................... 47

ARTICLE IX PLAN ADMINISTRATION ............................................................................................................. 49

ARTICLE X CLAIM PROCEDURES; PAYMENT OF CLAIMS ...................................................................... 51

ARTICLE XI COORDINATION OF BENEFITS ................................................................................................. 63

ARTICLE XII MEDICARE ..................................................................................................................................... 66

ARTICLE XIII THIRD PARTY RECOVERY, SUBROGATION AND REIMBURSEMENT ........................ 67

ARTICLE XIV MISCELLANEOUS PROVISIONS ............................................................................................. 71

ARTICLE XV MEDICAL BENEFITS .................................................................................................................... 73

ARTICLE XVI DENTAL BENEFITS ..................................................................................................................... 85

ARTICLE XVII PRESCRIPTION DRUG BENEFITS ......................................................................................... 90

ARTICLE XVIII HIPAA PRIVACY ....................................................................................................................... 93

ARTICLE XIX HIPAA SECURITY ........................................................................................................................ 99

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ARTICLE I

ESTABLISHMENT OF THE PLAN; ADOPTION OF THE PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

THIS PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION, made by Perry County (the “Plan Sponsor”)

as of January 1, 2012, hereby amends and restates the Perry County Employee Health Plan (the “Plan”), which was

originally adopted by the Company, effective October 1, 2010.

1.01 Effective Date

The Plan Document is effective as of the date first set forth above, and each amendment is effective as of the date set

forth therein.

1.02 Adoption of the Plan Document

The Plan Sponsor, as the settlor of the Plan, hereby adopts this Plan Document as the written description of the Plan.

This Plan Document represents both the Plan Document and the Summary Plan Description. This Plan Document

amends and replaces any prior statement of the health care coverage contained in the Plan or any predecessor to the

Plan.

IN WITNESS WHEREOF, the Plan Sponsor has caused this Plan Document to be executed.

Date: ___________________________________

Perry County

By: _____________________________________

Name: __________________________________

Title: ___________________________________

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ARTICLE II

INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION

2.01 Introduction and Purpose

The Plan Sponsor has established the Plan for the benefit of eligible Employees, in accordance with the terms and

conditions described herein. Plan benefits may be self-funded through a benefit fund or a trust established by the

Plan Sponsor and self-funded with contributions from Participants and/or the Plan Sponsor, or may be funded solely

from the general assets of the Plan Sponsor. Participants in the Plan may be required to contribute toward their

benefits.

The Plan Sponsor’s purpose in establishing the Plan is to help offset, for eligible Employees, the economic effects

arising from a Non-occupational Injury or Sickness. To accomplish this purpose, the Plan Sponsor must be

cognizant of the necessity of containing health care costs through effective plan design, and of abiding by the terms

of the Plan Document, to allow the Plan Sponsor to allocate the resources available to help those individuals

participating in the Plan to the maximum feasible extent.

The purpose of this Plan Document is to set forth the terms and provisions of the Plan that provide for the payment

or reimbursement of all or a portion of certain expenses for hospital, medical, prescription, vision or dental charges.

The Plan Document is maintained by the Plan Sponsor and may be inspected at any time during normal working

hours by any Participant.

2.02 General Plan Information

Name of Plan: Perry County Employee Health Plan

Plan Sponsor: Perry County

121 West Brown Street

New Lexington, OH 43764

740-432-9224

Plan Administrator:

(Named Fiduciary)

Perry County



740-432-9224

Plan Sponsor ID No. (EIN): 31-6400082

Source of Funding: Self-Funded

Applicable Law: Federal

State of Ohio

Plan Year: October 1 through September 30

Plan Type: Medical

Dental

Vision

Prescription Drug

Third Party Administrator: HealthSCOPE Benefits, Inc.

27 Corporate Hill Drive

Little Rock, AR 72205

501-225-1551

Participating Employer: Perry County

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Agent for Service of Process: Perry County

Plan Administrator



740-432-9224

2.03 Legal Entity; Service of Process

The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator.

2.04 Not a Contract

This Plan Document and any amendments constitute the terms and provisions of coverage under this Plan. The Plan

Document shall not be deemed to constitute a contract of any type between the Plan Sponsor and any Participant or

to be consideration for, or an inducement or condition of, the employment of any Employee. Nothing in this Plan

Document shall be deemed to give any Employee the right to be retained in the service of the Plan Sponsor or to

interfere with the right of the Plan Sponsor to discharge any Employee at any time; provided, however, that the

foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be

entered into by the Plan Sponsor with the bargaining representatives of any Employees.

2.05 Mental Health Parity

Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and

enforces parity between covered health care benefits and covered mental health and substance disorder benefits

relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the

Plan Administrator.

2.06 Applicable Law

The Plan is funded with employee and/or employer contributions. As such, when applicable, Federal law and

jurisdiction preempt State law and jurisdiction.

2.07 Discretionary Authority

The Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan provisions,

including the right to remedy possible ambiguities, inconsistencies and/or omissions in the Plan and related

documents; to make determinations in regards to issues relating to eligibility for benefits; to decide disputes that may

arise relative to a Plan Participants’ rights; and to determine all questions of fact and law arising under the Plan.

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ARTICLE III

SUMMARY OF BENEFITS

3.01 General Limits

Payment for any of the expenses listed below is subject to all Plan exclusions, limitations and provisions. All

coverage figures are after the out-of-pocket Deductible has been satisfied. Benefits for Pregnancy expenses are paid

the same as any other Sickness.

Failure to comply with Utilization Management will result in a higher cost to Participants. “Utilization

Management” includes hospital pre-admission certification, continued stay review, length-of-stay determination and

discharge planning. These programs are designed to ensure that Medically Necessary, high-quality patient care is

provided and enables maximum benefits under the Plan. See pre-certification requirements in the section entitled

“Cost Containment.”

The following services will require pre-certification (or reimbursement from the Plan may be reduced):

Inpatient Hospitalization;

Transplant Candidacy Evaluation and Transplant (organ and/or tissue);

Home Health Services;

Durable Medical Equipment, rental greater than 2 months, or purchase in excess of $500 billed per date of

service;

Rehab program (such as Cardiac, Chemical Dependency, Pain Management, Pulmonary);

Physical Therapy, Occupational Therapy, Speech Therapy or Cognitive Therapy;

Inpatient Mental/Nervous facility based programs;

Inpatient Substance Abuse facility based programs;

Skilled Nursing Facility stays;

Dialysis;

Use of Implantable Devices;

Infusion Services;

Prescription Specialty Drugs; and

MRI/PET/CT Scans.

Remember that although the Plan will automatically pre-authorize a maternity length of stay that is 48 hours or less

for a vaginal delivery or 96 hours for a cesarean delivery, it is important to have your Physician call to obtain pre-

certification in case there is a need to have a longer stay.

See pre-certification requirements in the section entitled “Cost Containment” for more details.

Notification is requested for the following services:

Outpatient surgical facility;

Hospice services;

Infusion services; and

High-tech radiology services.

The Plan contracts with the medical provider Networks to access discounted fees for service for Participants.

Hospitals, Physicians and other Providers who have contracted with the medical provider Networks are called

“Network Providers.” Those who have not contracted with the Networks are referred to in this Plan as “Non-

Network Providers.” This arrangement results in the following benefits to Participants:

1. The Plan provides different levels of benefits based on whether the Provider Participants use is a Network

or Non-Network Provider. Unless one of the exceptions shown below applies, if a Participant elects to

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receive medical care from the Non-Network Provider, the benefits payable are generally lower than those

payable when a Network Provider is used. The following exceptions apply:

a. In the event a Network Provider refers a Participant to a non-Network Provider for diagnostic testing,

x-rays, laboratory services or anesthesia, then charges of the non-Network Provider will be paid as

though the services were provided by a Network Provider.

b. The Network Provider level of benefits is payable for any Participant who cannot access Network

Providers because they reside outside the Network service area.

c. The Network Provider level of benefits is payable when a Participant receives emergency care either

Out of Area or at a Non-Network Hospital for an Accidental Bodily Injury or Emergency.

2. If the charge billed by a Non-Network Provider for any covered service is higher than the Usual and

Customary Fees determined by the Plan, Participants are responsible for the excess unless the Provider

accepts assignment of benefits as consideration in full for services rendered. Since Network Providers have

agreed to accept a negotiated discounted fee as full payment for their services, Participants are not

responsible for any billed amount that exceeds that fee.

3. To receive benefit consideration, Participants must submit claims for services provided by Non-Network

Providers to the Third Party Administrator. Network Providers have agreed to bill the Plan directly, so that

Participants do not have to submit claims themselves.

4. Benefits available to Network Providers are limited such that if a Network Provider advances or submits

charges which exceed amounts that are eligible for payment in accordance with the terms of the Plan, or are

for services or supplies for which Plan coverage is not available, or are otherwise limited or excluded by the

Plan, benefits will be paid in accordance with the terms of the Plan.

3.02 Primary Care Providers

A current list of PPO providers is available, without charge, through the Third Party Administrator’s website

(located at www.healthscopebenefits.com).

Each Participant has a free choice of any physician or surgeon, and the physician-patient relationship shall be

maintained. The Participant, together with his or her Physician, is ultimately responsible for determining the

appropriate course of medical treatment, regardless of whether the Plan will pay for all or a portion of the cost of

such care. The PPO providers are merely independent contractors; neither the Plan nor the Plan Administrator make

any warranty as to the quality of care that may be rendered by any PPO provider.

This Plan generally allows the designation of a primary care Provider. You have the right to designate any primary

care Provider who participates in the Network and who is available to accept you or your family members. For

information on how to select a primary care Provider, and for a list of the participating primary care Providers,

contact the Plan Administrator.

3.03 Claims Audit

In addition to the Plan’s Medical Record Review process, the Plan Administrator may use its discretionary authority

to utilize an independent bill review and/or claim audit program or service for a complete claim. While every claim

may not be subject to a bill review or audit, the Plan Administrator has the sole discretionary authority for selection

of claims subject to review or audit.

The analysis will be employed to identify charges billed in error and/or charges that are not Usual and Customary

and/or Medically Necessary and Reasonable, if any, and may include a patient medical billing records review and/or

audit of the patient’s medical charts and records.

Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the

charges deemed in excess of the Usual and Customary and Reasonable amounts or other applicable provisions, as

outlined in this Plan Document.

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Despite the existence of any agreement to the contrary, the Plan Administrator has the discretionary authority to

reduce any charge to a Usual and Customary and Reasonable charge, in accord with the terms of this Plan Document.

3.04 Calendar Year Maximum Benefit

The following calendar year maximums apply to each Participant:

Calendar Year Maximum Benefits for:

Chiropractic Care $1,000

All Essential Health Benefits $1,250,000

3.05 Summary of Medical Benefits

The following benefits are per Participant per Plan Year:

Network

Non-Network

Limits

Deductible

$350

$700

$700

$1,400

Individual

Family Unit

Payment Level (unless otherwise stated) 90% 70%

Maximum Out-of-pocket1

Individual

Family Unit

$1,000

$2,000

$1,500

$3,000

Covered Medical Expenses:

Network

Non-Network

Limits2

1. Allergy Services

PCP Office Visit

Specialist Office Visit

Testing

Serum or Inhaler

$15 Copay

$25 Copay

90% after Deductible

$5 Copay




$5 Copay

2. Ambulance 90% after Deductible 70% after Deductible Maximum benefit of

$1,250,0003

3. Ambulatory Surgical Center 90% after Deductible 70% after Deductible Notification is required

4. Anesthesia 90% after Deductible 70% after Deductible

5. Birthing Center 90% after Deductible 70% after Deductible

6. Blood & Plasma 90% after Deductible 70% after Deductible

7. Chemotherapy See section 15.01(8) below

8. Chiropractic Care 90% after Deductible 70% after Deductible $1,000 maximum

benefit

9. Dental (Injury)

PCP Office Visit


All Other Services

$15 Copay

$25 Copay





Dental services must be

received within 6

months of the injury

1 Excludes Deductibles, copayments and amounts over Usual and Customary Fees.

2 These limits are in addition to all other Plan exclusions, limitations and provisions set forth in this Plan. Please

review the Plan carefully to determine benefits available.

3 Maximum benefit is for ground and air ambulance transportation combined. Network and Non-Network

covered services apply to this maximum benefit.

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10. Dialysis, Outpatient See section 15.01(12) below

11. Durable Medical Equipment 90% after Deductible 70% after Deductible Rental is paid up to the

purchase price

12. Glaucoma, Cataract Surgery and

Lenses (one set) 90% after Deductible 70% after Deductible

13. Hearing Aids 100% no Deductible 100% no Deductible Maximum benefit of

$2,000 every 24 months

14. Home Health Care 90% after Deductible 70% after Deductible

15. Hospice Care

Inpatient

Outpatient

Family Bereavement

Counseling







Bereavement

counseling is limited to

2 visits per loss

16. Hospital

Inpatient Treatment

Outpatient Treatment





Private room is covered

up to the semi-private

room rate

17. Infertility Diagnosis

PCP Office Visit


Other Services

$15 Copay

$25 Copay





Limited to infertility

diagnosis only

18. Newborn Care 90% after Deductible 70% after Deductible

19. Outpatient Diagnostic X-ray and

Lab 90% no Deductible 70% after Deductible

MRI, MRA, PED and

CT require pre-

certification

20. Outpatient Emergency Services 85% after Deductible 85% after Deductible Deductible is waived if

patient is admitted

21. Pain Management Programs

PCP Office Visit


Other Services

$15 Copay

$25 Copay





22. Physician Services

PCP Office Visit


Lab, x-rays and Surgery

$15 Copay 70% after Deductible

$25 Copay

100% no Deductible



23. Podiatry Services

PCP Office Visit


Other Services

$15 Copay

$25 Copay





24. Pregnancy Expenses 90% no Deductible 70% after Deductible

25. Preventive Care – Well Adult

Care4

100% no Deductible

First $700 of charges

is paid at 100% no

Deductible. Balance

is paid at 70% after

Deductible.

4 Includes: 1 routine physical exam per benefit period; 1 routine gynecology exam per benefit period; routine

blood screening limited to $100 per benefit period; adult immunizations including Gardasil. Routine PSA,

mammogram and pap smear are not included in $700 limit. PSA screenings are limited to 1 per benefit period

and routine mammograms are limited as follows: 1 baseline for ages 35-39, 1 every 2 years for ages 40-49, and

1 annually for ages 50 and older.

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26. Preventive Care – Well Child Care

Routine Exam and Immunizations

Birth to Age 1

Ages 1 through 3

Ages 4 through 9

100% no Deductible

100% no Deductible

100% no Deductible

First $1,200 paid at

100% no deductible.

Balance is paid at

70% after Deductible.

First $500 paid at

100% no Deductible.

Balance is paid at


First $300 paid at

100% no Deductible.

Balance is paid at


27. Private Duty Nursing 90% after Deductible 70% after Deductible $5,000 maximum

benefit

28. Prosthetics, Orthotics, Supplies and

Surgical Dressings 90% after Deductible 70% after Deductible

Includes repair and

replacement. Excludes

routine maintenance.

29. Psychiatric Expenses

Residential Treatment

Inpatient Physician

Partial Day Program

Outpatient Physician









30. Second Surgical Opinions 100% no Deductible 100% no Deductible

31. Skilled Nursing Facility 90% after Deductible 70% after Deductible

32. Substance Abuse Benefits

Residential Treatment

Inpatient Physician

Partial Day Program

Outpatient Physician









33. Surgery 90% after Deductible 70% after Deductible

34. Temporomandibular Joint Disorder

(TMJ) 90% after Deductible 70% after Deductible

$500 maximum benefit

for Participants over

age 16. Surgical

treatment is not

covered.

35. Therapy

Occupational Therapy

Physical Therapy

Radiation Therapy

Respiration Therapy

Speech Therapy











Pre-certification is

required after the 10th

Physical and

Occupational Therapy

visit.

36. Tobacco Cessation5 100% no Deductible 70% after Deductible

37. Transplants 90% after Deductible 70% after Deductible Pre-certification is

required

5 Includes: routine screening for tobacco use; counseling for tobacco dependence treatment; all FDA-approved

nicotine replacement products and tobacco cessation medications (over-the-counter and prescription, Bupropion

SR, Varenicline and various forms of nicotine replacement) at least two courses per Plan Year. Benefits cover

at least two quit attempts per year with no lifetime limit on counseling or pharmacotherapy.

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38. Urgent Care Facility

PCP Office Visit


$15 Copay

$25 Copay



Network level copay is

waived if Participant is

admitted for the same

condition following

Urgent Care Facility

visit

39. Wigs 90% after deductible 70% after Deductible Limited to $1,000 per

Participant’s lifetime

3.06 Summary of Dental Benefits

The following Deductibles, maximums and benefits are per Participant:

Deductible per Individual per calendar year $50

Deductible per Family per calendar year $100

Maximum benefit per calendar year for Class 1, 2 and 3 Services $1,200

Maximum Lifetime benefit for Class 4 Services $1,200 per lifetime

Covered Dental Expenses: Benefits

Class 1 Services (Preventive Care) 100%

Class 2 Services (Repair and Restoration) 80%

Class 3 Services (Major Dental Repair) 60%

Class 4 Services (Orthodontics) 60%

3.07 Summary of Prescription Drug Benefits

The following benefits are per Participant:

Covered Prescription Drug Expenses:

Participating Pharmacy6

Pharmacy Option:

Copayment, per prescription or refill, for generic $7

Copayment, per prescription or refill, for formulary name brands7 $25

Copayment, per prescription or refill, for non-formulary name brands $40

Over-the-Counter Prilosec, Prevacid, Zegerid OTC and Omeprazole8 $0

Mail Order Option9:


Copayment, per prescription or refill, for name brands8 $50


6 100% payment by Plan after copayment.

7 Also includes cost difference between name brand and generic forms, unless prescription is not manufactured in

generic form or Physician has indicated “dispense as written” or similar indication.

8 Must be accompanied by a written request or prescription from the Physician and presented at the time of

purchase.

9 Prescription orders in excess of one refill must be obtained through the Mail Order Option in order to be eligible

for benefits under the Plan.

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ARTICLE IV

DEFINITIONS

The following words and phrases shall have the following meanings when used in the Plan Document. The

following definitions are not an indication that charges for particular care, supplies or services are eligible for

payment under the Plan, however they may be used to identify ineligible expenses; please refer to the

appropriate sections of the Plan Document for that information.

“Accident”

“Accident” shall mean a sudden and unforeseen event, or a deliberate act resulting in unforeseen consequences.

“Accidental Bodily Injury”

“Accidental Bodily Injury” shall mean an Injury sustained as the result of an Accident and independently of all other

causes by an outside traumatic event or due to exposure to the elements.

“Actively At Work” or “Active Employment”

“Actively At Work” or “Active Employment” shall mean performance by the Employee of all the regular duties of

his or her occupation at an established business location of the Participating Employer, or at another location to

which he or she may be required to travel to perform the duties of his or her employment. An Employee shall be

deemed Actively at Work if the Employee is absent from work due to a health factor. In no event will an Employee

be considered Actively at Work if he or she has effectively terminated employment.

“ADA”

“ADA” shall mean the American Dental Association.

“Adverse Benefit Determination”

“Adverse Benefit Determination” shall mean any of the following:

1. A denial in benefits;

2. A reduction in benefits;

3. A rescission of coverage;

4. A termination of benefits; or

5. A failure to provide or make payment (in whole or in part) for a benefit, including any such denial,

reduction, termination, or failure to provide or make payment that is based on a determination of a

Claimant’s eligibility to participate in the Plan.

“AHA”

“AHA” shall mean the American Hospital Association.

“Allowable Expenses”

“Allowable Expenses” shall mean the Usual and Customary charge for any Medically Necessary, Reasonable,

eligible item of expense, at least a portion of which is covered under a plan. When some Other Plan pays first in

accordance with Section 10.06A herein, this Plan’s Allowable Expenses shall consist of the Plan Participant's

responsibility, if any, after the Other Plan has paid but shall in no event exceed the Other Plan’s Allowable

Expenses. When some Other Plan provides benefits in the form of services rather than cash payments, the

reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of

the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include the benefits that would

have been payable had claim been duly made therefore.

“Alternate Recipient”

“Alternate Recipient” shall mean any Child of a Participant who is recognized under a Medical Child Support Order

as having a right to enrollment under this Plan as the Participant’s Eligible Dependent. For purposes of the benefits

provided under this Plan, an Alternate Recipient shall be treated as an Eligible Dependent.

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“AMA”

“AMA” shall mean the American Medical Association.

“Ambulatory Surgical Center”

“Ambulatory Surgical Center” shall mean any public or private State licensed and approved (whenever required by

law) establishment with an organized medical staff of Physicians, with permanent facilities that are equipped and

operated primarily for the purpose of performing Surgical Procedures, with continuous Physician services and

registered professional nursing service whenever a patient is in the facility, and which does not provide service or

other accommodations for patients to stay overnight.

“Assignment of Benefits”

“Assignment of Benefits” shall mean an arrangement whereby the Plan Participant assigns their right to seek and

receive payment of eligible Plan benefits, in strict accordance with the terms of this Plan Document, to a Provider. If

a provider accepts said arrangement, Providers’ rights to receive Plan benefits are equal to those of a Plan

Participant, and are limited by the terms of this Plan Document. A Provider that accepts this arrangement indicates

acceptance of an “Assignment of Benefits” as consideration in full for services, supplies, and/or treatment rendered.

“Birthing Center”

“Birthing Center” shall mean a facility that meets professionally recognized standards and all of the following

requirements:

1. It mainly provides an outpatient setting for childbirth following a normal, uncomplicated Pregnancy, in a

home-like atmosphere.

2. It has the following: at least 2 delivery rooms; all the medical equipment needed to support the services

furnished by the facility; laboratory diagnostic facilities; and emergency equipment, trays, and supplies for

use in life threatening situations.

3. It has medical staff that: is supervised by a Physician on a full-time basis; and includes a Registered Nurse

at all times when Covered Persons are at the facility.

4. If it is not part of a Hospital, it has a written agreement with a local Hospital and a local ambulance

company for the immediate transfer of Covered Persons who develop complications or who require either

pre or post-natal care.

5. It admits only Covered Persons who: have undergone an educational program to prepare them for the birth;

and have medical records of adequate prenatal care.

6. It schedules confinements of not more than 24 hours for a birth.

7. It maintains medical records for each Covered Person.

8. It complies with all licensing and other legal requirements that apply.

9. It is not the office or clinic of one or more Physicians or a specialized facility other than a Birthing Center.

“Cardiac Care Unit”

“Cardiac Care Unit” shall mean a separate, clearly designated service area which is maintained within a Hospital and

which meets all the following requirements:

1. It is solely for the treatment of patients who require special medical attention because of their critical

condition;

2. It provides within such area special nursing care and observation of a continuous and constant nature not

available in the regular rooms and wards of the Hospital;

3. It provides a concentration of special lifesaving equipment immediately available at all times for the

treatment of patients confined within such area;

4. It contains at least two beds for the accommodation of critically ill patients; and

5. It provides at least one professional registered nurse, who continuously and constantly attends the patient

confined in such area on a 24-hour-a-day basis.

“Centers of Excellence”

“Centers of Excellence” shall mean medical care facilities that have met stringent criteria for quality care in the

specialized procedures of organ transplantation. These centers have the greatest experience in performing transplant

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procedures and the best survival rates. The Plan Administrator shall determine what Network Centers of Excellence

are to be used.

Any Participant in need of an organ transplant may contact the Claims Administrator to initiate the pre-certification

process resulting in a referral to a Center of Excellence. The Claims Administrator acts as the primary liaison with

the Center of Excellence, patient and attending Physician for all transplant admission taking place at a Center of

Excellence.

If a Participant chooses not to use a Center of Excellence, the payment for services will be limited to what would

have been the cost at the nearest Center of Excellence.

Additional information about this option, as well as a list of Centers of Excellence, will be given to covered

Employees and updated as requested.

“Certificate of Coverage”

“Certificate of Coverage” shall mean a written certification provided by any source that offers medical care

coverage, including the Plan, for the purpose of confirming the duration and type of an individual’s previous

coverage.

“Child”

“Child” shall mean, in addition to the Employee’s own blood descendant of the first degree or lawfully adopted

Child, a Child placed with a covered Employee in anticipation of adoption, a covered Employee’s Child who is an

alternate recipient under a Qualified Medical Child Support Order as required by the Federal Omnibus Budget

Reconciliation Act of 1993, any stepchild, an “eligible foster child,” which is defined as an individual placed with

the Employee by an authorized placement agency or by judgment, decree or other order of a court of competent

jurisdiction or any other Child for whom the Employee has obtained legal guardianship.

“CHIP”

“CHIP” refers to the Children’s Health Insurance Program or any provision or section thereof, which is herein

specifically referred to, as such act, provision or section may be amended from time to time.

“CHIPRA”

“CHIPRA” refers to the Children’s Health Insurance Program Reauthorization Act of 2009 or any provision or

section thereof, which is herein specifically referred to, as such act.

“Chiropractic Care”

“Chiropractic Care” shall mean office visits, x-rays, manipulations, supplies, heat treatment, cold treatment, and

massages.

“Claim Determination Period”

“Claim Determination Period” shall mean each calendar year.

“Clean Claim”

A “Clean Claim” is one that can be processed in accordance with the terms of this document without obtaining

additional information from the service Provider or a third party. It is a claim which has no defect or impropriety. A

defect or impropriety shall include a lack of required sustaining documentation as set forth and in accordance with

this document, or a particular circumstance requiring special treatment which prevents timely payment as set forth in

this document, and only as permitted by this document, from being made. A Clean Claim does not include claims

under investigation for fraud and abuse or claims under review for Medical Necessity and Reasonableness, or fees

under review for Usual and Customariness, or any other matter that may prevent the charge(s) from being covered

expenses in accordance with the terms of this document.

Filing a Clean Claim. A Provider submits a Clean Claim by providing the required data elements on the standard

claims forms, along with any attachments and additional elements or revisions to data elements, attachments and

additional elements, of which the Provider has knowledge. The Plan Administrator may require attachments or other

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information in addition to these standard forms (as noted elsewhere in this document and at other times prior to claim

submittal) to ensure charges constitute covered expenses as defined by and in accordance with the terms of this

document. The paper claim form or electronic file record must include all required data elements and must be

complete, legible, and accurate. A claim will not be considered to be a Clean Claim if the Plan Participant has failed

to submit required forms or additional information to the Plan as well.

“COBRA”

“COBRA” shall mean the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

“Cosmetic Surgery”

“Cosmetic Surgery” shall mean any Surgery, service, Drug or supply designed to improve the appearance of an

individual by alteration of a physical characteristic which is within the broad range of normal but which may be

considered unpleasing or unsightly, except when necessitated by an Injury.

“Covered Expense”

“Covered Expense” means a Usual and Customary fee for a Reasonable, Medically Necessary service, treatment or

supply, meant to improve a condition or participant’s health, which is eligible for coverage in this Plan. Covered

Expenses will be determined based upon all other Plan provisions. When more than one treatment option is

available, and one option is no more effective than another, the Covered Expense is the least costly option that is no

less effective than any other option.

All treatment is subject to benefit payment maximums shown in the Summary of Benefits and as determined

elsewhere in this document.

“Covered Mental Health Service Providers”

“Covered Mental Health Service Providers” are physicians and associated visits which are limited and subject to the

Summary of Benefits and terms of this document. Psychiatrists (M.D.), psychologists (Ph.D.) or counselors licensed

to provide individual psychotherapy without supervision in the State they are practicing, may bill the Plan directly.

Other licensed mental health practitioners must be under the direction of and must bill the Plan through these

professionals.

“Creditable Coverage”

“Creditable Coverage” shall mean coverage of an individual under any of the following: a group health plan, health

insurance coverage, Medicare, Medicaid (other than coverage consisting solely of benefits under the program for

distribution of pediatric vaccines), medical and dental care for members and certain former members of the

Uniformed Services and their dependents, a medical care program of the Indian Health Service or a tribal

organization, a State health benefits risk pool, a health plan offered under the Federal Employees Health Benefits

Program, a public health plan, or a health benefit plan under Section 5(e) of the Peace Corps Act, or Title XXI of the

Social Security Act (State Children’s Health Insurance Program). To the extent that further clarification is needed

with respect to the sources of Creditable Coverage listed in the prior sentence, please see the complete definition of

Creditable Coverage that is set forth in 45 C.F.R. § 146.113(a).

“Custodial Care”

“Custodial Care” shall mean care or confinement provided primarily for the maintenance of the Participant,

essentially designed to assist the Participant, whether or not Totally Disabled, in the activities of daily living, which

could be rendered at home or by persons without professional skills or training. This care is not reasonably expected

to improve the underlying medical condition, even though it may relieve symptoms or pain. Such care includes, but

is not limited to, bathing, dressing, feeding, preparation of special diets, assistance in walking or getting in and out of

bed, supervision over medication which can normally be self-administered and all domestic activities.

“Deductible”

“Deductible” shall mean an amount of money that is paid once a Plan year per Participant and Family Unit.

Typically, there is one Deductible amount per Plan and it must be paid before any money is paid by the Plan for any

covered services. Each Plan year, a new Deductible amount is required. Deductibles do not accrue toward the

100% maximum out-of-pocket payment.

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“Dentist”

“Dentist” shall mean an individual holding a D.D.S. or D.M.D. degree, licensed to practice dentistry in the

jurisdiction where such services are provided.

“Dependent”

“Dependent” shall mean one or more of the following person(s):

1. An Employee’s lawfully married spouse possessing a marriage license who is not divorced from the

Employee and who does not have access to health plan coverage through their own employer. Spouses

enrolled in the plan before April 30, 2012 continue to be eligible for this Plan despite having access to

health plan coverage through their own employer. For purposes of this section, “marriage or married”

means a legal union between one man and one woman as husband and wife;

2. An Employee’s Child who is less than 26 years of age; and

3. An Employee’s Child, regardless of age, who was continuously covered prior to attaining the limiting age

under the bullets above, who is mentally or physically incapable of sustaining his or her own living. Such

Child must have been mentally or physically incapable of earning his or her own living prior to attaining the

limiting age under the bullets above. Written proof of such incapacity and dependency satisfactory to the

Plan must be furnished and approved by the Plan within 31 days after the date the Child attains the limiting

age under the bullets above. The time limit for written proof of incapacity and dependency is 31 days

following the original eligibility date for a new or re-enrolling Employee. The Plan may require, at

reasonable intervals, subsequent proof satisfactory to the Plan during the next two years after such date.

After such two year period, the Plan may require such proof, but not more often than once each year.

“Dependent” does not include any person who is a member of the armed forces of any Country or who is a resident

of a Country outside the United States.

The Plan reserves the right to require documentation, satisfactory to the Plan Administrator, which establishes a

Dependent relationship.

“Detoxification”

“Detoxification” shall mean the process whereby an alcohol-intoxicated person or person experiencing the symptoms

of Substance Abuse is assisted, in a facility licensed by the Department of Health, through the period of time

necessary to eliminate, by metabolic or other means, the intoxicating alcohol, alcohol dependency factors or alcohol

in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient

at a minimum.

“Diagnostic Service”

“Diagnostic Service” shall mean a test or procedure performed for specified symptoms to detect or to monitor a

Disease or condition. It must be ordered by a Physician or other professional Provider.

“Disease”

“Disease” shall mean any disorder which does not arise out of, which is not caused or contributed to by, and which is

not a consequence of, any employment or occupation for compensation or profit; however, if evidence satisfactory to

the Plan is furnished showing that the individual concerned is covered as an employee under any worker’s

compensation law, occupational disease law or any other legislation of similar purpose, or under the maritime

doctrine of maintenance, wages, and cure, but that the disorder involved is one not covered under the applicable law

or doctrine, then such disorder shall, for the purposes of the Plan, be regarded as a Sickness, Illness or Disease.

“Drug”

“Drug” shall mean insulin and prescription legend drugs. A prescription legend drug is a Federal legend drug (any

medicinal substance which bears the legend: “Caution: Federal law prohibits dispensing without a prescription”) or

a State restricted drug (any medicinal substance which may be dispensed only by prescription, according to State

law) and which, in either case, is legally obtained from a licensed drug dispenser only upon a prescription of a

currently licensed Physician.

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“Durable Medical Equipment”

“Durable Medical Equipment” shall mean equipment which:

1. Can withstand repeated use;

2. Is primarily and customarily used to serve a medical purpose;

3. Generally is not useful to a person in the absence of an Illness or Injury; and

4. Is appropriate for use in the home.

“Emergency”

“Emergency” shall mean a situation where necessary treatment is required as the result of a sudden and severe

medical event or acute condition. An Emergency includes poisoning, shock, and hemorrhage. Other Emergencies

and acute conditions may be considered on receipt of proof, satisfactory to the Plan, that an Emergency did exist.

The Plan may, at its own discretion, request satisfactory proof that an Emergency or acute condition did exist.

“Emergency Medical Condition”

“Emergency Medical Condition” shall mean a medical condition manifesting itself by acute symptoms of sufficient

severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and

medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in

clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act (42 U.S.C. 1395dd(e)(1)(A)). In that

provision of the Social Security Act, clause (i) refers to placing the health of the individual (or, with respect to a

pregnant woman, the health of the woman or her unborn child) in serious jeopardy; clause (ii) refers to serious

impairment to bodily functions; and clause (iii) refers to serious dysfunction of any bodily organ or part.

“Emergency Services”

“Emergency Services” shall mean, with respect to an Emergency Medical Condition:

1. A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C.

1395dd) that is within the capability of the emergency department of a Hospital, including ancillary services

routinely available to the emergency department to evaluate such Emergency Medical Condition; and

2. Such further medical examination and treatment, to the extent they are within the capabilities of the staff

and facilities available at the Hospital, as are required under section 1867 of the Social Security Act (42

U.S.C. 1395dd) to stabilize the patient.

“Employee”

“Employee” shall mean a person who is a regular full-time Employee of the Participating Employer, regularly

scheduled to work for the Participating Employer in an employer-Employee relationship. Such person must be

scheduled to work at least 25 hours per week in order to be considered “full-time.”

“Essential Health Benefits”

“Essential Health Benefits” shall mean, under section 1302(b) of the Patient Protection and Affordable Care Act,

those health benefits to include at least the following general categories and the items and services covered within the

categories: ambulatory patient services; Emergency Services; hospitalization; maternity and newborn care; mental

health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative

and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease

management; and pediatric services, including oral and vision care.

“Experimental” and/or “Investigational”

“Experimental” and/or “Investigational” (“Experimental”) shall mean services or treatments that are not widely used

or accepted by most practitioners or lack credible evidence to support positive short or long-term outcomes from

those services or treatments; these services are not included under or as Medicare reimbursable procedures, and

include services, supplies, care, procedures, treatments or courses of treatment which:

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1. Do not constitute accepted medical practice under the standards of the case and by the standards of a

reasonable segment of the medical community or government oversight agencies at the time rendered; or

2. Are rendered on a research basis as determined by the United States Food and Drug Administration and the

AMA’s Council on Medical Specialty Societies.

All phases of clinical trials shall be considered Experimental.

A drug, device, or medical treatment or procedure is Experimental:

1. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug

Administration and approval for marketing has not been given at the time the drug or device is furnished;

2. If reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing

Phase I, II, or III clinical trials or under study to determine its:

a) maximum tolerated dose;

b) toxicity;

c) safety;

d) efficacy; and

e) efficacy as compared with the standard means of treatment or diagnosis; or

3. if reliable evidence shows that the consensus among experts regarding the drug, device, or medical

treatment or procedure is that further studies or clinical trials are necessary to determine its:

a) maximum tolerated dose;

b) toxicity;

c) safety;

d) efficacy; and

e) efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean:

1. Only published reports and articles in the authoritative medical and scientific literature;

2. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying

substantially the same drug, device, or medical treatment or procedure; or

3. The written informed consent used by the treating facility or by another facility studying substantially the

same drug, device, or medical treatment or procedure.

In the context of drugs used in the treatment of cancer, the use of a drug will not be considered Experimental

and/or Investigational where either (1) the use of the drug has been recognized as safe and effective for the

treatment of the specific type of cancer in the National Comprehensive Cancer Network’s Drugs and Biologics

Compendium, Thomson Micromedex DRUGDEX, Thomson Micromedex DrugPoints or Clinical Pharmacology

or (2) the drug is provided in association with a Phase II, III or IV trial for cancer, as approved by the FDA or

sanctioned by the National Cancer Institute (“NCI”) or an NCI-sponsored group and standard treatment (i) has

been or would be ineffective, (ii) does not exist, or (iii) there is no clearly superior non-investigational alternative

that can be delivered more cost efficiently, each as determined by the Plan Sponsor.

The Plan Administrator retains maximum legal authority and discretion to determine what is Experimental.

“Family Unit”

“Family Unit” shall mean the Employee, his or her spouse and Children.

“FMLA”

“FMLA” shall mean the Family and Medical Leave Act of 1993, as amended.

“FMLA Leave”

“FMLA Leave” shall mean a leave of absence, which the Company is required to extend to an Employee under the

provisions of the FMLA.

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“GINA”

“GINA” shall mean the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110-233), which

prohibits group health plans, issuers of individual health care policies, and employers from discriminating on the

basis of genetic information.

“Health Breach Notification Rule”

“Health Breach Notification Rule” shall mean 16 CFR Part 318.

“HIPAA”

“HIPAA” shall mean the Health Insurance Portability and Accountability Act of 1996, as amended.

“Home Health Care”

“Home Health Care” shall mean the continual care and treatment of an individual if:

1. The institutionalization of the individual would otherwise have been required if home health care was not

provided;

2. The treatment plan covering the home health care service is established and approved in writing by the

attending Physician; and

3. The home health care is the result of an Illness or Injury.

“Home Health Care Agency”

“Home Health Care Agency” shall mean an agency or organization which provides a program of home health care

and which:

1. Is approved as a Home Health Agency under Medicare;

2. Is established and operated in accordance with the applicable laws in the jurisdiction in which it is located

and, where licensing is required, has been licensed and approved by the regulatory authority having the

responsibility for licensing; or

3. Meets all of the following requirements:

a. It is an agency which holds itself forth to the public as having the primary purpose of providing a

home health care delivery system bringing supportive services to the home;

b. It has a full-time administrator;

c. It maintains written records of services provided to the patient;

d. Its staff includes at least one registered nurse (R.N.) or it has nursing care by a registered nurse

(R.N.) available; and

e. Its employees are bonded and it provides malpractice insurance.

“Hospital”

“Hospital” shall mean an Institution that meets all of the following requirements:

1. It provides medical and Surgical facilities for the treatment and care of Injured or Sick persons on an

Inpatient basis;

2. It is under the supervision of a staff of Physicians;

3. It provides 24-hour-a-day nursing service by registered nurses;

4. It is duly licensed as a hospital, except that this requirement will not apply in the case of a State tax-

supported Institution;

5. It is not, other than incidentally, a place for rest, a place for the aged, a nursing home or a custodial or

training-type Institution, or an Institution which is supported in whole or in part by a Federal government

fund; and

6. It is accredited by the Joint Commission on Accreditation of Hospitals sponsored by the AMA and the

AHA.

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The requirement of surgical facilities shall not apply to a Hospital specializing in the care and treatment of mentally

ill patients, provided such Institution is accredited as such a facility by the Joint Commission on Accreditation of

Hospitals sponsored by the AMA and the AHA.

“Hospital” shall also have the same meaning, where appropriate in context, set forth in the definition of

“Ambulatory Surgical Center.”

“Illness”

“Illness” shall have the meaning set forth in the definition of “Disease.”

“Impregnation and Infertility Treatment”

“Impregnation and Infertility Treatment” shall mean artificial insemination, fertility drugs, G.I.F.T. (Gamete

Intrafallopian Transfer), impotency drugs such as Viagra™, in-vitro fertilization, sterilization and/or reversal of a

sterilization operation, surrogate mother, donor eggs, or any type of artificial impregnation procedure, whether or not

such procedure is successful.

“Incurred”

“Incurred” shall mean that a covered expense is Incurred on the date the service is rendered or the supply is obtained.

With respect to a course of treatment or procedure which includes several steps or phases of treatment, covered

expenses are Incurred for the various steps or phases as the services related to each step are rendered and not when

services relating to the initial step or phase are rendered. More specifically, covered expenses for the entire

procedure or course of treatment are not Incurred upon commencement of the first stage of the procedure or course

of treatment.

“Injury”

“Injury” shall mean an Accidental Bodily Injury, which does not arise out of, which is not caused or contributed to

by, and which is not a consequence of, any employment or occupation for compensation or profit.

“Inpatient”

“Inpatient” shall mean any person who, while confined to a Hospital, is assigned to a bed in any department of the

Hospital other than its outpatient department and for whom a charge for Room and Board is made by the Hospital.

“Institution”

“Institution” shall mean a facility, operating within the scope of its license, whose purpose is to provide organized

health care and treatment to individuals, such as a Hospital, Ambulatory Surgical Center, Psychiatric Hospital,

community mental health center, residential treatment facility, psychiatric treatment facility, Substance Abuse

Treatment Center, alternative birthing center, Home Health Care Center, or any other such facility that the Plan

approves.

“Intensive Care Unit”

“Intensive Care Unit” shall have the same meaning set forth in the definition of “Cardiac Care Unit.”

“Late Enrollee”

“Late Enrollee” shall mean a Participant who enrolls in the Plan other than:

1. On the earliest date on which coverage can become effective for the individual under the terms of the Plan;

or

2. Through special enrollment.

“Leave of Absence”

“Leave of Absence” shall mean a leave of absence of an Employee that has been approved by his or her Participating

Employer, as provided for in the Participating Employer’s rules, policies, procedures and practices.

“Mastectomy”

“Mastectomy” shall mean the surgical removal of all or part of a breast.

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“Maximum Amount” or “Maximum Allowable Charge”

“Maximum Amount” and/or “Maximum Allowable Charge” shall mean the benefit payable for a specific coverage

item or benefit under the Plan. Maximum Allowable Charge(s) will be the lesser of:

The Usual and Customary amount;

The allowable charge specified under the terms of the Plan;

The negotiated rate established in a contractual arrangement with a Provider; or

The actual billed charges for the covered services.

The Plan will reimburse the actual charge billed if it is less than the Usual and Customary amount. The Plan has the

discretionary authority to decide if a charge is Usual and Customary and for a Medically Necessary and Reasonable

service.

The Maximum Allowable Charge will not include any identifiable billing mistakes including, but not limited to,

up-coding, duplicate charges, and charges for services not performed.

“Medical Child Support Order”

“Medical Child Support Order” shall mean any judgment, decree or order (including approval of a domestic relations

settlement agreement) issued by a court of competent jurisdiction that:

1. Provides for child support with respect to a Participant’s Child or directs the Participant to provide

coverage under a health benefits plan pursuant to a State domestic relations law (including a community

property law); or

2. Enforces a law relating to medical child support described in Social Security Act §1908 (as added by

Omnibus Budget Reconciliation Act of 1993 §13822) with respect to a group health plan.

“Medically Necessary”

“Medical Care Necessity”, “Medically Necessary”, “Medical Necessity” and similar language refers to health care

services ordered by a Physician exercising prudent clinical judgment provided to a Plan Participant for the purposes

of evaluation, diagnosis or treatment of that Plan Participant’s Sickness or Injury. Such services, to be considered

Medically Necessary, must be clinically appropriate in terms of type, frequency, extent, site and duration for the

diagnosis or treatment of the Plan Participant’s Sickness or Injury. The Medically Necessary setting and level of

service is that setting and level of service which, considering the Plan Participant’s medical symptoms and

conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically

Necessary must be no more costly than alternative interventions, including no intervention and are at least as likely

to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Plan Participant’s

Sickness or Injury without adversely affecting the Plan Participant’s medical condition.

A) It must not be maintenance therapy or maintenance treatment.

B) Its purpose must be to restore health.

C) It must not be primarily custodial in nature.

D) It must not be a listed item or treatment not allowed for reimbursement by CMS (Medicare).

E) The Plan reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of

treatment as additional criteria for determination of Medical Necessity and/or an Allowable Expense.

For Hospital stays, this means that acute care as an Inpatient is necessary due to the kind of services the Participant is

receiving or the severity of the Participant’s condition and that safe and adequate care cannot be received as an

outpatient or in a less intensified medical setting. The mere fact that the service is furnished, prescribed or approved

by a Physician does not mean that it is “Medically Necessary.” In addition, the fact that certain services are excluded

from coverage under this Plan because they are not “Medically Necessary” does not mean that any other services are

deemed to be “Medically Necessary.”

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To be Medically Necessary, all of these criteria must be met. Merely because a Physician or Dentist recommends,

approves, or orders certain care does not mean that it is Medically Necessary. The determination of whether a

service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical

Association and the Plan Administrator’s own medical advisors. The Plan Administrator has the discretionary

authority to decide whether care or treatment is Medically Necessary.

“Medical Record Review”

“Medical Record Review” is the process by which the Plan, based upon a medical record review and audit,

determines that a different treatment or different quantity of a drug or supply was provided which is not supported in

the billing, then the Plan Administrator may determine the Maximum Allowable Charge according to the medical

record review and audit results.

“Medicare”

“Medicare” shall mean the program of health care for the aged established by Title XVIII of the Social Security Act

of 1965, as amended.

“Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”)”

“Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”)” shall mean in the case of a group health

plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical

benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that:

1. The financial requirements applicable to such mental health or substance use disorder benefits are no more

restrictive than the predominant financial requirements applied to substantially all medical and surgical

benefits covered by the Plan (or coverage) and that there are no separate cost sharing requirements that are

applicable only with respect to mental health or substance use disorder benefits. If these benefits are

covered by the group health plan (or health insurance coverage is offered in connection with such a plan);

and

2. The treatment limitations applicable to such mental health or substance use order benefits are no more

restrictive than the predominant treatment limitations applied to substantially all medical and surgical

benefits covered by the Plan (or coverage), and that there are no separate treatment limitations that are

applicable only with respect to mental health or substance use disorder benefits. If these benefits are

covered by the group health plan (or health insurance coverage offered in connection with such a plan).

“Mental or Nervous Disorder”

“Mental or Nervous Disorder” shall mean any disease or condition, regardless of whether the cause is organic, that is

classified as a Mental or Nervous Disorder in the current edition of International Classification of Diseases,

published by the U.S. Department of Health and Human Services, is listed in the current edition of Diagnostic and

Statistical Manual of Mental Disorders, published by the American Psychiatric Association or other relevant State

guideline or applicable sources.

“National Medical Support Notice” or “NMSN”

“National Medical Support Notice” or “NMSN” shall mean a notice that contains the following information:

1. Name of an issuing State agency;

2. Name and mailing address (if any) of an employee who is a Participant under the Plan;

3. Name and mailing address of one or more Alternate Recipients (i.e., the child or children of the Participant

or the name and address of a substituted official or agency that has been substituted for the mailing address

of the Alternate Recipients(s)); and

4. Identity of an underlying child support order.

“Network”

“Network” shall mean the medical provider network the Plan contracts to access discounted fees for service for

Participants. The Network Provider will be identified on the Participants identification card.

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“No-Fault Auto Insurance”

“No-Fault Auto Insurance” is the basic reparations provision of a law providing for payments without determining

fault in connection with automobile accidents.

“Non-Occupational Injury”

“Non-occupational Injury” shall have the meaning set forth in the definition of “Injury.”

“Non Network Fee Schedule (NNFS)”

“Non Network Fee Schedule (NNFS)” is a fee schedule used to re-price non-network claims.

“Open Enrollment Period”

“Open Enrollment Period” shall mean the period of time determined by the Plan Administrator in each Plan Year.

Generally, the first two weeks in September, however this is subject to change.

“Other Plan”

“Other Plan” shall include, but is not limited to:

1. Any primary payer besides the Plan;

2. Any other group health plan;

3. Any other coverage or policy covering the Participant;

4. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage,

uninsured or underinsured motorist coverage;

5. Any policy of insurance from any insurance company or guarantor of a responsible party;

6. Any policy of insurance from any insurance company or guarantor of a third party;

7. Worker’s compensation or other liability insurance company; or

8. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other

benefit payments, and school insurance coverage.

“Out of Area”

“Out of Area” shall mean a geographic area, as determined by the Plan Administrator, at the time each Participant

becomes eligible for coverage under this Plan.

“Participant” / “Plan Participant”

“Participant” shall mean any Employee or Dependent who is eligible for benefits under the Plan.

“Physician”

“Physician” shall mean a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery

(D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Psychologist (Ph.D.), psychiatrist or midwife.

“Plan Year”

“Plan Year” shall mean a period commencing on the Effective Date or any anniversary of the adoption of this Plan

and continuing until the next succeeding anniversary.

“Pre-admission Tests”

“Pre-admission Tests” shall mean those Diagnostic Services done prior to scheduled Surgery, provided that:

1. The tests are approved by both the Hospital and the Physician;

2. The tests are performed on an outpatient basis prior to Hospital admission; and

3. The tests are performed at the Hospital into which confinement is scheduled, or at a qualified facility

designated by the Physician who will perform the Surgery.

“Pregnancy”

“Pregnancy” shall mean carrying a child, resulting childbirth, miscarriage and non-elective abortion. The Plan

considers Pregnancy as a Sickness for the purpose of determining benefits.

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“Pre-existing Condition”

“Pre existing Condition” is any Sickness, Illness, Disease or Injury (other than Pregnancy), regardless of cause, for

which medical advice, diagnosis, care or treatment was recommended or received, by or from a Provider or

practitioner duly licensed to provide such care under applicable State law and operating within the scope of practice

authorized by such State law, during the 6 months immediately prior to the date an Employee’s Service Waiting

Period commences (the “Enrollment Date”).

Coverage will be available for such condition on the day immediately following the expiration of 12 months after the

Enrollment Date. A Participant has the right to demonstrate any Creditable Coverage, and the applicable period

shall be reduced by any Creditable Coverage unless that Creditable Coverage occurred before a Significant Break in

Coverage.

“Prior Plan”

“Prior Plan” shall mean the coverage provided on a group or group-type basis by the group insurance policy, benefit

plan or service plan that was terminated on the day before the Effective Date of the Plan and replaced by the Plan.

“Prior to Effective Date” or “After Termination Date”

“Prior to Effective Date” or “After Termination Date” are dates occurring before a Participant gains eligibility from

the Plan, or dates occurring after a Participant loses eligibility from the Plan, as well as charges incurred prior to the

effective date of coverage under the Plan or after coverage is terminated, unless Extension of Benefits applies.

“Privacy Standards”

“Privacy Standards” shall mean the standards of the privacy of individually identifiable health information, as

pursuant to HIPAA.

“Provider”

“Provider” shall mean a Physician, a licensed speech or occupational therapist, licensed professional physical

therapist, physiotherapist, audiologist, speech language pathologist, licensed professional counselor, certified nurse

practitioner, certified psychiatric/mental health clinical nurse, or other practitioner or facility defined or listed herein,

or approved by the Plan Administrator.

“Psychiatric Hospital”

“Psychiatric Hospital” shall mean an Institution constituted, licensed, and operated as set forth in the laws that apply

to Hospitals, which meets all of the following requirements:

1. It is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill

persons either by, or under the supervision of, a Physician;

2. It maintains clinical records on all patients and keeps records as needed to determine the degree and

intensity of treatment provided;

3. It is licensed as a psychiatric hospital;

4. It requires that every patient be under the care of a Physician; and

5. It provides 24-hour-a-day nursing service.

The term Psychiatric Hospital does not include an Institution, or that part of an Institution, used mainly for nursing

care, rest care, convalescent care, care of the aged, Custodial Care or educational care.

“Qualified Medical Child Support Order” or “QMCSO”

“Qualified Medical Child Support Order” or “QMCSO” is a Medical Child Support Order that creates or recognizes

the existence of an Alternate Recipient’s right to, or assigns to an Alternate Recipient the right to, receive benefits

for which a Participant or Eligible Dependent is entitled under this Plan.

“Reasonable”

“Reasonable” and/or “Reasonableness” shall mean in the administrator’s discretion, services or supplies, or fees for

services or supplies which are necessary for the care and treatment of illness or injury not caused by the treating

Provider. Determination that fee(s) or services are reasonable will be made by the Plan Administrator, taking into

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consideration unusual circumstances or complications requiring additional time, skill and experience in connection

with a particular service or supply; industry standards and practices as they relate to similar scenarios; and the cause

of injury or illness necessitating the service(s) and/or charge(s).

This determination will consider, but will not be limited to, the findings and assessments of the following entities: (a)

The National Medical Associations, Societies, and organizations; and (b) The Food and Drug Administration. To be

Reasonable, service(s) and/or fee(s) must be in compliance with generally accepted billing practices for unbundling

or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that are

clearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable. The Plan

Administrator retains discretionary authority to determine whether service(s) and/or fee(s) are Reasonable based

upon information presented to the Plan Administrator. A finding of Provider negligence and/or malpractice is not

required for service(s) and/or fee(s) to be considered not Reasonable.

Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for payment (exceed the

Maximum Allowable Charge), when they result from Provider error(s) and/or facility-acquired conditions deemed

“reasonably preventable” through the use of evidence-based guidelines, taking into consideration but not limited to

CMS guidelines.

The Plan reserves for itself and parties acting on its behalf the right to review charges processed and/or paid by the

Plan, to identify charge(s) and/or service(s) that are not Reasonable and therefore not eligible for payment by the

Plan.

“Rehabilitation Hospital”

“Rehabilitation Hospital” shall mean an Institution which mainly provides therapeutic and restorative services to

Sick or Injured people. It is recognized as such if:

1. It carries out its stated purpose under all relevant Federal, State and local laws;

2. It is accredited for its stated purpose by either the Joint Commission on Accreditation of Hospitals or the

Commission on Accreditation for Rehabilitation Facilities; or

3. It is approved for its stated purpose by Medicare.

“Room and Board”

“Room and Board” shall mean a Hospital’s charge for:

1. Room and linen service;

2. Dietary service, including meals, special diets and nourishment;

3. General nursing service; and

4. Other conditions of occupancy which are Medically Necessary.

“Scheduled benefit” or “Scheduled benefit amount” means a specified dollar amount that will be considered for

reimbursement under the Plan for a particular type of medical care, service or supply provided. Scheduled benefits

are based upon covered expenses not otherwise limited or excluded under the terms of the Plan. A partial listing of

scheduled benefit amounts may be found in the section, “Summary of Benefits”.

“Security Standards”

“Security Standards” shall mean the final rule implementing HIPAA’s Security Standards for the Protection of

Electronic PHI, as amended.

“Service Waiting Period”

“Service Waiting Period” shall mean an interval of time during which the Employee is in the continuous, Active

Employment of his or her Participating Employer.

“Sickness”

“Sickness” shall have the meaning set forth in the definition of “Disease.”

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“Significant Break in Coverage”

“Significant Break in Coverage” shall mean a period of 63 consecutive days during each of which an individual does

not have any Creditable Coverage.

“Substance Abuse”

“Substance Abuse” shall mean any use of alcohol, any Drug (whether obtained legally or illegally), any narcotic, or

any hallucinogenic or other illegal substance, which produces a pattern of pathological use, causing impairment in

social or occupational functioning, or which produces physiological dependency evidenced by physical tolerance or

withdrawal. It is the excessive use of a substance, especially alcohol or a drug. The DSM-IV definition is applied as

follows:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as

manifested by one (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or

home (e.g., repeated absences or poor work performance related to substance use; substance-

related absences, suspensions or expulsions from school; neglect of children or household);

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an

automobile or operating a machine when impaired by substance use);

3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct);

or

4. Continued substance use despite having persistent or recurrent social or interpersonal problems

caused or exacerbated by the effects of the substance (e.g., arguments with spouse about

consequences of intoxication, physical fights);

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

“Substance Abuse Treatment Center”

“Substance Abuse Treatment Center” shall mean an Institution which provides a program for the treatment of

Substance Abuse by means of a written treatment plan approved and monitored by a Physician. This Institution must

be:

1. Affiliated with a Hospital under a contractual agreement with an established system for patient referral;

2. Accredited as such a facility by the Joint Commission on Accreditation of Hospitals; or

3. Licensed, certified or approved as an alcohol or Substance Abuse treatment program or center by a State

agency having legal authority to do so.

Substance Dependence: Substance use history which includes the following: (1) substance abuse (see above); (2)

continuation of use despite related problems; (3) development of tolerance (more of the drug is needed to achieve the

same effect); and (4) withdrawal symptoms.

“Surgery”

“Surgery” shall mean any of the following:

1. The incision, excision, debridement or cauterization of any organ or part of the body, and the suturing of a

wound;

2. The manipulative reduction of a fracture or dislocation or the manipulation of a joint including application

of cast or traction;

3. The removal by endoscopic means of a stone or other foreign object from any part of the body or the

diagnostic examination by endoscopic means of any part of the body;

4. The induction of artificial pneumothorax and the injection of sclerosing solutions;

5. Arthrodesis, paracentesis, arthrocentesis and all injections into the joints or bursa;

6. Obstetrical delivery and dilatation and curettage; or

7. Biopsy.

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“Surgical Procedure”

“Surgical Procedure” shall have the same meaning set forth in the definition of “Surgery.”

“Total Disability”

“Total Disability” shall mean an individual is determined as being disabled for Social Security purposes and

provides such evidence to the Plan of the determination as the Plan Administrator may, in its sole discretion, require.

“Totally Disabled”

“Totally Disabled” shall have the same meaning set forth in the definition of “Total Disability.”

“Uniformed Services”

“Uniformed Services” shall mean the Armed Forces, the Army National Guard and the Air National Guard, when

engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps

of the Public Health Service, and any other category of persons designated by the President of the United States in

time of war or Emergency.

“USERRA”

“USERRA” shall mean the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”).

“Usual and Customary”

“Usual and Customary” (U&C) shall mean covered expenses which are identified by the Plan Administrator, taking

into consideration the fee(s) which the Provider most frequently charges the majority of patients for the service or

supply, the cost to the Provider for providing the services, the prevailing range of fees charged in the same “area” by

Providers of similar training and experience for the service or supply, and the Medicare reimbursement rates. The

term(s) “same geographic locale” and/or “area” shall be defined as a metropolitan area, county, or such greater area

as is necessary to obtain a representative cross-section of Providers, persons or organizations rendering such

treatment, services, or supplies for which a specific charge is made. To be Usual and Customary, fee(s) must be in

compliance with generally accepted billing practices for unbundling or multiple procedures.

The term “Usual” refers to the amount of a charge made for medical services, care, or supplies, to the extent that the

charge does not exceed the common level of charges made by other medical professionals with similar credentials, or

health care facilities, pharmacies, or equipment suppliers of similar standing, which are located in the same

geographic locale in which the charge is incurred.

The term “Customary” refers to the form and substance of a service, supply, or treatment provided in accordance

with generally accepted standards of medical practice to one individual, which is appropriate for the care or

treatment of the same sex, comparable age and who receive such services or supplies within the same geographic

locale.

The term “Usual and Customary” does not necessarily mean the actual charge made nor the specific service or

supply furnished to a Plan Participant by a Provider of services or supplies, such as a physician, therapist, nurse,

hospital, or pharmacist. The Plan Administrator will determine what the Usual and Customary charge is, for any

procedure, service, or supply, and whether a specific procedure, service or supply is Usual and Customary.

Usual and Customary charges may, at the Plan Administrator’s discretion, alternatively be determined and

established by the Plan using normative data such as, but not limited to, Medicare cost to charge ratios, average

wholesale price (AWP) for prescriptions and/or manufacturer’s retail pricing (MRP) for supplies and devices.

All other defined terms in this Plan Document shall have the meanings specified

in the Plan Document where they appear.

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ARTICLE V

ELIGIBILITY FOR COVERAGE

SPECIAL RESTRICTIONS FOR PRE-EXISTING CONDITIONS

5.01 Eligibility for Individual Coverage

Each Employee will become eligible for coverage under this Plan with respect to himself or herself on the first day of

the month following completion of a Service Waiting Period of 31 days, provided the Employee has begun work for

his or her Participating Employer. If the Employee is unable to begin work as scheduled, then his or her coverage

will become effective on such later date when the Employee begins work. Each Employee who was covered under

the Prior Plan, if any, will be eligible on the Effective Date of this Plan. Any Service Waiting Period or portion

thereof satisfied under the Prior Plan, if any, will be applied toward satisfaction of the Service Waiting Period of this

Plan.

5.02 Eligibility Dates for Dependent Coverage

Each Employee will become eligible for coverage under this Plan for his or her Dependents on the latest of the

following dates:

1. His or her date of eligibility for coverage for himself or herself under the Plan;

2. The date coverage for his or her Dependents first becomes available under any amendment to the Plan, if

such coverage was not provided under the Plan on the Effective Date of the Plan; and

3. The first date upon which he or she acquires a Dependent.

Any reference in this Plan to an Employee’s Dependent being covered means that such Employee is covered for

Dependent Coverage.

Note: Spouses of Employee’s will not be eligible for coverage under this Plan if they have access to coverage

through their own employer. This does not apply to spouses who were enrolled in the Plan prior to April 30, 2012.

5.03 Effective Dates of Coverage; Conditions

The coverage for which an individual is eligible under this Plan will become effective on the date specified below,

subject to the conditions of this section.

1. Enrollment Form. Coverage for an Employee or his or her Dependents must be requested by the Employee

on a form furnished by the Plan Administrator and will become effective on the date such Employee or

Dependents are eligible, provided the Employee has enrolled for such coverage on a form satisfactory to the

Plan Administrator within the 31-day period immediately following the date of eligibility.

2. Birth of Dependent Child. If a Dependent Child is born after the date the Employee’s coverage for himself

or herself under the Plan becomes effective and the Employee has coverage under this Plan for his or her

Dependents, coverage shall take effect from and after the moment of birth, to the extent of the benefits

provided herein, and any limitations of this Plan with respect to Pre-existing Conditions or congenital

defects shall not apply to such Child. Such coverage shall continue for the 31-day period commencing on

the date of birth. In order to continue such coverage after the 31st day, prior to the end of the 31-day period,

the Employee must make written application to the Plan for such Child and agree to make any required

contribution.

If the Employee does not have coverage under this Plan for any Dependents at the date of such Child’s

birth, then coverage for such Child shall be available only if, during the first 31 days following the date of

birth, the Employee makes written application to the Plan for such Child and agrees to make any required

contribution. In that event, coverage will be effective as of the moment of birth, to the extent of the benefits

provided herein, and any limitations of this Plan with respect to Pre-existing Conditions or congenital

defects shall not apply to such Child.

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3. Newly Acquired Dependents. If an Employee acquires a Dependent while the Employee is eligible for

coverage for Dependents, coverage for the newly acquired Dependent shall be effective on the date the

Dependent becomes eligible, provided application is made to the Plan within 31 days of the date of

eligibility and any required contributions are made.

The Pre-existing Condition limitation does not apply to your Child that has not yet reached age 19.

4. Requirement for Employee Coverage. No coverage for Dependents of an Employee will become effective

unless the Employee is, or simultaneously becomes, eligible for coverage for himself or herself under the

Plan.

5. Medicaid Coverage. An individual’s eligibility for any State Medicaid benefits will not be taken into

account by the Plan in determining that individual’s eligibility under the Plan.

6. FMLA Leave. Regardless of any requirements set forth in the Plan, the Plan shall at all times comply with

FMLA.

5.04 Special and Open Enrollment

The Plan provides special enrollment periods that allow Employee’s to enroll in the Plan, even if they declined

enrollment during an initial or subsequent eligibility period.

5.04A Loss of Other Coverage

If an Employee declined enrollment for himself or herself or his or her Dependents (including his or her spouse)

because of other health coverage, he or she may enroll for coverage for himself or herself and/or his or her

Dependents if the other health coverage is lost. The Employee must make written application for special enrollment

within 31 days of the date the other health coverage was lost. For example, if the Employee loses his or her other

health coverage on March 1, he or she must notify the Plan Administrator and apply for coverage by close of

business on March 31.

The following conditions apply to any eligible Employee and Dependents:

An Employee may enroll during this special enrollment period:

1. If the Employee is eligible for coverage under the terms of this Plan;

2. The Employee is not currently enrolled under the Plan;

3. When enrollment was previously offered, the Employee declined because of coverage under another group

health plan or health insurance coverage. The Employee must have provided a written statement that other

health coverage was the reason for declining enrollment under this Plan; and

4. If the other coverage was terminated due to loss of eligibility for the coverage (including due to legal

separation, divorce, death, termination of employment, or reduction in the number of hours), or because

employer contributions for the coverage were terminated.

An Employee who is already enrolled in a benefit package may enroll in another benefit package under the Plan if a

Dependent of that Employee has a special enrollment right in the Plan because the Dependent lost eligibility for

other coverage. The Employee must make written application for special enrollment in the new benefit package

within 30 days of the date the other health coverage was lost.

The Employee is not eligible for this special enrollment right if:

1. The other coverage was COBRA continuation coverage and the Employee did not exhaust the maximum

time available to him or her for that COBRA coverage; or

2. The other coverage was lost due to non-payment of requisite contribution / premium or for cause (such as

making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the other

plan).

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If the conditions for special enrollment are satisfied, coverage for the Employee and/or his or her Dependent(s) will

be effective at 12:01 A.M. on the first day of the first calendar month beginning after the date the written request is

received by the Plan.

5.04B New Dependent

If an Employee acquires a new Dependent as a result of marriage, birth, adoption, or placement for adoption, he or

she may be able to enroll himself or herself and his or her Dependents during a special enrollment period. The

Employee must make written application for special enrollment no later than 31 days after he or she acquires the new

Dependent. For example, if the Employee is married on March 1, he or she must notify the Plan Administrator and

apply for coverage by close of business on March 31.

The following conditions apply to any eligible Employee and Dependents:

An Employee may enroll himself or herself and/or his or her eligible Dependents during this special enrollment

period if:

1. The Employee is eligible for coverage under the terms of this Plan; and

2. The Employee has acquired a new Dependent through marriage, birth, adoption, or placement for adoption.

If the conditions for special enrollment are satisfied, coverage for the Employee and his or her Dependent(s) will be

effective at 12:01 A.M.:

1. For a marriage, on the day after the marriage;

2. For a birth, on the date of birth; or

3. For an adoption or placement for adoption, on the date of the adoption or placement for adoption.

5.04C Additional Special Enrollment Rights

Employees and Dependents who are eligible but not enrolled are entitled to enroll under the following

circumstances:

1. The Employee’s or Dependent’s Medicaid or State Child Health Insurance Plan (i.e. CHIP) coverage has

terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60

days after the termination; or

2. The Employee or Dependent become eligible for a contribution / premium assistance subsidy under

Medicaid or a State Child Health Insurance Plan (i.e. CHIP), and the Employee requests coverage under the

Plan within 60 days after eligibility is determined.

5.04D Open Enrollment

Participants may enroll for coverage during Open Enrollment Periods. Coverage for Participants enrolling during an

Open Enrollment Period will become effective on October 1, unless the Employee has not satisfied the Service

Waiting Period, in which event coverage for the Employee and his or her Dependents will become effective on the

day following completion of the Service Waiting Period.

“Open Enrollment Period” shall mean the period of time as determined by the Plan Administrator in each Plan

Year. Generally, the first two weeks of September, subject to change.

5.04E Effective Date of Coverage; Conditions

All conditions for effectiveness of coverage under the Plan, which are set forth in the section entitled “Effective

Dates of Coverage; Conditions,” will apply to Participants enrolling during a Special or Open Enrollment Period.

Coverage for Participants enrolling during a Special Enrollment Period will become effective on the first day

following the enrollment due to loss of coverage or marriage, and on the date of birth, adoption or placement for

adoption in the case of such events.

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5.05 Qualified Medical Child Support Orders

The Plan Administrator shall enroll for immediate coverage under this Plan any Alternate Recipient who is the

subject of a Medical Child Support Order that is a “Qualified Medical Child Support Order” (“QMCSO”) if such an

individual is not already covered by the Plan as an Eligible Dependent, once the Plan Administrator has determined

that such order meets the standards for qualification set forth below.

“Alternate Recipient” shall mean any Child of a Participant who is recognized under a Medical Child Support

Order as having a right to enrollment under this Plan as the Participant’s Eligible Dependent. For purposes of the

benefits provided under this Plan, an Alternate Recipient shall be treated as an Eligible Dependent.

“Medical Child Support Order” shall mean any judgment, decree or order (including approval of a domestic

relations settlement agreement) issued by a court of competent jurisdiction that:

1. Provides for child support with respect to a Participant’s Child or directs the Participant to provide

coverage under a health benefits plan pursuant to a State domestic relations law (including a community

property law); or

2. Enforces a law relating to medical child support described in Social Security Act §1908 (as added by

Omnibus Budget Reconciliation Act of 1993 §13822) with respect to a group health plan.

“National Medical Support Notice” or “NMSN” shall mean a notice that contains the following information:

1. Name of an issuing State agency;

2. Name and mailing address (if any) of an employee who is a Participant under the Plan;

3. Name and mailing address of one or more Alternate Recipients (i.e., the child or children of the Participant

or the name and address of a substituted official or agency that has been substituted for the mailing address

of the Alternate Recipients(s)); and

4. Identity of an underlying child support order.

“Qualified Medical Child Support Order” or “QMCSO” is a Medical Child Support Order that creates or

recognizes the existence of an Alternate Recipient’s right to, or assigns to an Alternate Recipient the right to, receive

benefits for which a Participant or Eligible Dependent is entitled under this Plan. In order for such order to be a

QMCSO, it must clearly specify the following:

1. The name and last known mailing address (if any) of the Participant and the name and mailing address of

each such Alternate Recipient covered by the order;

2. A reasonable description of the type of coverage to be provided by the Plan to each Alternate Recipient, or

the manner in which such type of coverage is to be determined;

3. The period of coverage to which the order pertains; and

4. The name of this Plan.

In addition, a National Medical Support Notice shall be deemed a QMCSO if it:

1. Contains the information set forth above in the definition of “National Medical Support Notice”;

2. a. Identifies either the specific type of coverage or all available group health coverage. If the Employer

receives an NMSN that does not designate either specific type(s) of coverage or all available coverage,

the Employer and the Plan Administrator will assume that all are designated;

b. Informs the Plan Administrator that, if a group health plan has multiple options and the participant is

not enrolled, the issuing agency will make a selection after the NMSN is qualified, and, if the agency

does not respond within 20 days, the child will be enrolled under the Plan’s default option (if any); and

3. Specifies that the period of coverage may end for the Alternate Recipient(s) only when similarly situated

dependents are no longer eligible for coverage under the terms of the Plan, or upon the occurrence of

certain specified events.

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However, such an order need not be recognized as “qualified” if it requires the Plan to provide any type or form of

benefit, or any option, not otherwise provided to the Participants and Eligible Plan Participants without regard to this

section, except to the extent necessary to meet the requirements of a State law relating to medical child support

orders, as described in Social Security Act §1908 (as added by Omnibus Budget Reconciliation Act of 1993

§13822).

Upon receiving a Medical Child Support Order, the Plan Administrator shall, as soon as administratively possible:

1. Notify the Participant and each Alternate Recipient covered by the Order (at the address included in the

Order) in writing of the receipt of such Order and the Plan’s procedures for determining whether the Order

qualifies as a QMCSO; and

2. Make an administrative determination if the order is a QMCSO and notify the Participant and each affected

Alternate Recipient of such determination.

Upon receiving a National Medical Support Notice, the Plan Administrator shall:

1. Notify the State agency issuing the notice with respect to the child whether coverage of the child is available

under the terms of the Plan and, if so:

a. Whether the child is covered under the Plan; and

b. Either the effective date of the coverage or, if necessary, any steps to be taken by the custodial parent

or by the official of a State or political subdivision to effectuate the coverage; and

2. Provide to the custodial parent (or any State official serving in a substitute capacity) a description of the

coverage available and any forms or documents necessary to effectuate such coverage.

To give effect to this requirement, the Plan Administrator shall:

1. Establish reasonable, written procedures for determining the qualified status of a Medical Child Support

Order or National Medical Support Notice; and

2. Permit any Alternate Recipient to designate a representative for receipt of copies of the notices that are sent

to the Alternate Recipient with respect to the Order.

5.06 Special Restrictions for Pre-existing Conditions

A Pre-existing Condition limitation will apply for all Employees and Dependents entering or reentering the Plan after

the Effective Date, except as set forth in the Health Insurance Portability and Accountability Act of 1996

(“HIPAA”). No coverage is provided for expenses in connection with a Pre-existing Condition.

A “Pre-existing Condition” is any Sickness, Illness, Disease or Injury (other than Pregnancy), regardless of cause,

for which medical advice, diagnosis, care or treatment was recommended or received, by or from a health care

Provider or practitioner duly licensed to provide such care under applicable State law and operating within the scope

of practice authorized by such State law, during the 6 months immediately prior to the date an Employee’s Service

Waiting Period commences (the “Enrollment Date”).

Coverage will be available for such condition on the day immediately following the expiration of 12 months or, in

the case of a Late Enrollee, 12 months after the Enrollment Date. A Participant has the right to demonstrate any

Creditable Coverage, and the applicable period shall be reduced by any Creditable Coverage unless that Creditable

Coverage occurred before a Significant Break in Coverage.

The Pre-existing Condition limitation does not apply to any Participant or Dependent that has not yet reached age 19.

“Late Enrollee” shall mean a Participant who enrolls in the Plan other than:

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1. On the earliest date on which coverage can become effective for the individual under the terms of the Plan;

or

2. Through special enrollment.

5.06A Proof of Creditable Coverage

A Participant may prove Creditable Coverage by either of two methods:

1. For Creditable Coverage effective on or after July 1, 1996, the Participant may present a written Certificate

of Coverage from the source or entity that provided the coverage showing:

a. The date the Certificate was issued;

b. The name of the group health plan that provided the coverage;

c. The name of the Participant or Dependent to whom the Certificate applies;

d. The name, address, and telephone number of the plan administrator or issuer providing the

Certificate;

e. A telephone number for further information (if different);

f. Either:

(1) A statement that the Participant or Dependent has at least 18 months (546 days) of

Creditable Coverage, not counting days of coverage before a Significant Break in

Coverage; or

(2) The date any waiting period (and affiliation period, if applicable) began and the date

Creditable Coverage began; and

g. The date Creditable Coverage ended, unless the Certificate indicates that coverage is continuing as

of the date of the Certificate; or

2. If the Participant for any reason is unable to obtain a Certificate from another plan (including because the

Creditable Coverage was effective prior to July 1, 1996), he or she may demonstrate Creditable Coverage

by other evidence, including but not limited to documents, records, third-party statements, or telephone calls

by this Plan to a third-party Provider. This Plan will treat a Participant as having provided a Certificate if

that individual:

a. Attests to the period of Creditable Coverage;

b. Presents relevant corroborating evidence of some Creditable Coverage during the period; and

c. Cooperates with the Plan Administrator’s efforts to verify his or her status.

A Participant has the right to request a Certificate from his or her prior health plan, and the Plan Administrator will

help the Participant in obtaining the Certificate.

5.06B Notice of Pre-existing Condition Exclusion

If, within a reasonable time after receiving the information about Creditable Coverage described in the section

entitled “Proof of Creditable Coverage,” the Plan Administrator determines that an exclusion for Pre-existing

Conditions applies, it will notify the Participant of that conclusion and will specify the source of any information on

which it relied in reaching the determination. Such notification will also explain the Plan’s appeals procedures and

give the Participant a reasonable opportunity to present additional evidence.

If the Plan Administrator later determines that an individual did not have the claimed Creditable Coverage, the Plan

Administrator may modify its initial determination to the contrary. In that case, the individual will be notified of the

reconsideration; however, until a final determination is reached, the Plan Administrator will act in accordance with

its initial determination in favor of the Participant for the purpose of approving medical services.

5.06C Pre-existing Condition Exception

With respect to a Qualified Plan Participant who elects COBRA Continuation Coverage pursuant to the American

Recovery and Reinvestment Act of 2009 and the Department of Defense Appropriations Act, 2010, the following

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periods shall be disregarded for purposes of determining the 63-day break in coverage period, as referred to in

Section 701(c)(2) of ERISA:

1. The period beginning on the date of the Qualifying Event; and

2. The period ending with the start of COBRA Continuation Coverage.

Any Participant or Dependent that has not yet reached the age of 19 is not subject to the Pre-existing Condition

limitation(s) described herein.

5.07 Acquired Companies

Eligible Employees of an acquired company who are Actively at Work and were covered under the prior plan of the

acquired company will be eligible for the benefits under this Plan on the date of acquisition. Any waiting period

previously satisfied under the prior health plan will be applied toward satisfaction of the Service Waiting Period of

this Plan. In the event that an acquired company did not have a health plan, all eligible Employees will be eligible on

the date of the acquisition.

5.08 “GINA”

“GINA” prohibits group health plans, issuers of individual health care policies, and employers from discriminating

on the basis of genetic information.

The term “genetic information” means, with respect to any individual, information about:

1. Such individual’s genetic tests;

2. The genetic tests of family members of such individual; and

3. The manifestation of a disease or disorder in family members of such individual.

The term “genetic information” includes participating in clinical research involving genetic services. Genetic tests

would include analysis of human DNA, RNA, chromosomes, proteins, or metabolite that detect genotypes,

mutations, or chromosomal changes. Genetic information is a form of Protected Health Information (PHI) as defined

by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is subject

to applicable Privacy and Security Standards.

Family members as it relates to GINA include dependents, plus all relatives to the fourth degree, without regard to

whether they are related by blood, marriage, or adoption. Underwriting as it relates to GINA includes any rules for

determining eligibility, computing premiums or contributions, and applying preexisting conditions. Offering reduced

premiums or other rewards for providing genetic information would be impermissible underwriting.

GINA will not prohibit a health care Provider who is treating an individual from requesting that the patient undergo

genetic testing. The rules permit the Plan to obtain genetic test results and use them to make claims payment

determinations when it is necessary to do so to determine whether the treatment provided to the patient was

medically advisable and/or necessary.

The Plan may request, but not require, genetic testing in certain very limited circumstances involving research, so

long as the results are not used for underwriting, and then only with written notice to the individual that participation

is voluntary and will not affect eligibility for benefits, premiums or contributions. In addition, the Plan will notify

and describe its activity to the Health and Human Services secretary of its activities falling within this exception.

While the Plan may collect genetic information after initial enrollment, it may not do so in connection with any

annual renewal process where the collection of information affects subsequent enrollment. The Plan will not adjust

premiums or increase group contributions based upon genetic information, request or require genetic testing or

collect genetic information either prior to or in connection with enrollment or for underwriting purposes.

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ARTICLE VI

TERMINATION OF COVERAGE

6.01 Termination Dates of Individual Coverage

The coverage of any Employee for himself or herself under this Plan will terminate on the earliest to occur of the

following dates:

1. The date of termination of the Plan;

2. The day of the month in, or with respect to which, he or she requests that such coverage be terminated,

provided such request is made on or before such date;

3. The date of the expiration of the last period for which the Employee has made a contribution, in the event of

his or her failure to make, when due, any contribution for coverage for himself or herself to which he or she

has agreed in writing;

4. The date of the month in which he or she ceases to be eligible for such coverage under the Plan;

5. The date and time of the month in which the termination of employment occurs; or

6. Immediately after an Employee or his or her Dependent submits, or has knowledge of the submission of, a

fraudulent claim or any fraudulent information to the Plan, including enrollment information.

6.02 Termination Dates of Dependent Coverage

The coverage for any Dependents of any Employee who are covered under the Plan will terminate on the earliest to

occur of the following dates:

1. The date of termination of the Plan;

2. Upon the discontinuance of coverage for Dependents under the Plan;

3. The date of termination of the Employee’s coverage for himself or herself under the Plan;

4. The date of the expiration of the last period for which the Employee has made a contribution, in the event of

his or her failure to make, when due, any contribution for coverage for Dependents to which he or she has

agreed in writing;

5. In the case of a Child age 26 or older for whom coverage is being continued due to mental or physical

inability to earn his or her own living, the earliest to occur of:

a. Cessation of such inability;

b. Failure to furnish any required proof of the uninterrupted continuance of such inability or to submit

to any required examination; or

c. Upon the Child’s no longer being dependent on the Employee for his or her support;

6. The day immediately preceding the date such person ceases to be a Dependent, as defined herein, except as

may be provided for in other areas of this section; or

7. Immediately after an Employee or his or her Dependent submits, or has knowledge of the submission of, a

fraudulent claim or any fraudulent information to the Plan, including enrollment information.

6.03 Certificates of Coverage

The Plan generally will automatically provide a Certificate of Coverage to anyone who loses coverage in the Plan.

In addition, a Certificate of Coverage will be provided upon request, at any time while the individual is covered

under a plan and up to 24 months after the individual loses coverage under the Plan.

The Plan will make reasonable efforts to collect information applicable to any Dependents and to include that

information on the Certificate of Coverage, but the Plan will not issue an automatic Certificate of Coverage for

Dependents until the Plan has reason to know that a Dependent is or has been covered under the Plan.

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ARTICLE VII

CONTINUATION OF COVERAGE

7.01 Employer Continuation Coverage

Coverage will be continued for eligible Participants should the following occur:

1. In the event of a layoff, coverage will continue until the first day of the calendar month following the date of

layoff;

2. In the event of Total Disability, coverage will continue until the first day of the calendar month following

termination of Active Employment; or

3. In the event of a leave of absence which does not meet the requirements of FMLA Leave, coverage will

continue until the Employer approved leave ends.

7.02 Continuation During FMLA Leave

Regardless of the established leave policies mentioned above, the Plan shall at all times comply with FMLA. During

any leave taken under FMLA, the Employee will maintain coverage under this Plan on the same conditions as

coverage would have been provided if the covered Employee had been continuously employed during the entire

leave period.

The Family and Medical Leave Act is a Federal law that applies, generally, to employers with 50 or more

Employees, and provides that an eligible Employee may elect to continue coverage under this Plan during a period of

approved FMLA Leave at the same cost as if the leave had not been taken.

If provisions under the Plan change while an Employee is on FMLA Leave, the changes will be effective for him or

her on the same date as they would have been had he or she not taken leave.

7.02A Eligible Employees

Employees are eligible for FMLA Leave if all of the following conditions are met:

1. The Employee has been employed with the Participating Employer for at least 12 months;

2. The Employee has been employed with the Participating Employer at least 1,250 hours during the 12

consecutive months prior to the request for FMLA Leave; and

3. The Employee is employed at a worksite that employs at least 50 employees within a 75-mile radius.

7.02B Qualifying Circumstances for FMLA Leave

Coverage under FMLA Leave is limited to a total of 12 workweeks during any 12-month period that follows:

1. The birth of, and to care for, a Son or Daughter;

2. The placement of a Child with the Employee for adoption or foster care;

3. The Employee’s taking leave to care for his or her Spouse, Son or Daughter, or Parent who has a Serious

Health Condition;

4. The Employee’s taking leave due to a Serious Health Condition which makes him or her unable to perform

the functions of his or her position; or,

5. A Qualifying Exigency arising out of the fact that a Spouse, Son, Daughter, or Parent of the Employee is a

member of a regular or reserve component of the Armed Forces and is on (or has been notified of

impending call to) covered active duty.

Coverage under FMLA Leave is limited to a total of 26 workweeks during any 12-month period for the following

situations:

1. To care for a service member following a Serious Illness or Injury to that service member, when the

Employee is that service member’s Spouse, Son or Daughter, Parent, or Next of Kin; or

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2. To care for a veteran who is undergoing medical treatment, recuperation, or therapy for a Serious Illness or

Injury that occurred any time during the five years preceding the date of treatment, when the Employee is

that veteran’s Spouse, Son or Daughter, Parent, or Next of Kin.

This leave may be considered as a paid (accrued vacation time, personal leave or family or sick leave, as applicable)

or unpaid leave. The Participating Employer has the right to require that all paid leave be used prior to providing

any unpaid leave.

An Employee must continue to pay his or her portion of the Plan contribution, if any, during the FMLA Leave.

Payment must be made within 30 days of the due date established by the Plan Administrator. If payment is not

received, coverage will terminate on the last date for which the contribution was received in a timely manner.

7.02C Notice Requirements

An Employee must provide at least 30 days’ notice to his or her Participating Employer prior to beginning any leave

under FMLA. If the nature of the leave does not permit such notice, the Employee must provide notice of the leave

as soon as possible. The Participating Employer has the right to require medical certification to support the

Employee’s request for leave due to a Serious Health Condition for the Employee or his or her eligible family

members.

7.02D Length of Leave

During any one 12-month period, the maximum amount of FMLA Leave may not exceed 12 workweeks for most

FMLA related situations. The maximum periods for an Employee who is the primary care giver of a service member

with a Serious Illness or Injury that was Incurred in the line of active duty may take up to 26 weeks of FMLA Leave

in a single 12-month period to care for that service member. The Participating Employer may use any of four

methods for determining this 12-month period.

If the Employee and his or her Spouse are both employed by the Participating Employer, FMLA Leave may be

limited to a combined period of 12 workweeks, for both Spouses, when FMLA Leave is due to:

1. The birth or placement for adoption or foster care of a Child; or

2. The need to care for a Parent who has a Serious Health Condition.

7.02E Termination of FMLA Leave

Coverage may end before the maximum 12-week (or 26-week) period under the following circumstances:

1. When the Employee informs his or her Participating Employer of his or her intent not to return from leave;

2. When the employment relationship would have terminated but for the leave (such as during a reduction in

force);

3. When the Employee fails to return from the leave;

4. If any required Plan contribution is not paid within 30 days of its due date;

5. The Participating Employer and/or Plan Administrator is advised and/or determines that no FMLA

Qualifying Circumstance occurred.

If an Employee does not return to work when coverage under FMLA Leave ends, he or she will be eligible for

COBRA continuation of coverage at that time, in accordance with the parameters set forth by this Plan and applicable

law.

7.02F Recovery of Plan Contributions

The Participating Employer has the right to recover the portion of the Plan contributions it paid to maintain coverage

under the Plan during an unpaid FMLA Leave if an Employee does not return to work at the end of the leave. This

right will not apply if failure to return is due to the continuation, recurrence or onset of a Serious Health Condition

that entitles the Employee to FMLA Leave (in which case the Participating Employer may require medical

certification) or other circumstances beyond the Employee’s control.

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7.02G Reinstatement of Coverage

The law requires that coverage be reinstated upon the Employee’s return to work following an FMLA Leave whether

or not the Employee maintained coverage under the Plan during the FMLA Leave.

On reinstatement, all provisions and limits of the Plan will apply as they would have applied if FMLA Leave had not

been taken. The Service Waiting Period and the Pre-existing Condition limitation will be credited as if the

Employee had been continually covered under the Plan.

7.02H Definitions

For this provision only, the following terms are defined as stated.

“Next of Kin”

“Next of Kin” shall mean the nearest blood relative to the service member.

“Parent”

“Parent” shall mean the Employee’s biological parent or someone who has acted as his or her parent in place of his

or her biological parent when he or she was a Son or Daughter.

“Qualifying Exigency”

“Qualifying Exigency” shall mean:

1. Short-notice deployment.

a. To address any issue that arises from the fact that a covered military member is notified seven or less

calendar days prior to the date of deployment of an impending call or order to active duty in support of

a contingency operation; and

b. Leave taken for this purpose can be used for a period of seven calendar days beginning on the date a

covered military member is notified of an impending call or order to active duty in support of a

contingency operation;

2. Military events and related activities.

a. To attend any official ceremony, program, or event sponsored by the military that is related to the active

duty or call to active duty status of a covered military member; and

b. To attend family support or assistance programs and informational briefings sponsored or promoted by

the military, military service organizations, or the American Red Cross that are related to the active duty

or call to active duty status of a covered military member;

3. Childcare and school activities.

a. To arrange for alternative childcare when the active duty or call to active duty status of a covered

military member necessitates a change in the existing childcare arrangement for a biological, adopted, or

foster Child, a stepchild, or a legal ward of a covered military member, or a Child for whom a covered

military member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of

self-care because of a mental or physical disability at the time that FMLA Leave is to commence;

b. To provide childcare on an urgent, immediate need basis (but not on a routine, regular, or everyday

basis) when the need to provide such care arises from the active duty or call to active duty status of a

covered military member for a biological, adopted, or foster Child, a stepchild, or a legal ward of a

covered military member, or a Child for whom a covered military member stands in loco parentis, who

is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical

disability at the time that FMLA Leave is to commence;

c. To enroll in or transfer to a new school or daycare facility, a biological, adopted, or foster Child, a

stepchild, or a legal ward of the covered military member, or a Child for whom the covered military

member stands in loco parentis, who is either under age 18, or age 18 or older and incapable of self-care

because of a mental or physical disability at the time that FMLA Leave is to commence, when

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enrollment or transfer is necessitated by the active duty or call to active duty status of a covered military

member; and

d. To attend meetings with staff at a school or a daycare facility, such as meetings with school officials

regarding disciplinary measures, parent-teacher conferences, or meetings with school counselors, for a

biological, adopted, or foster Child, a stepchild, or a legal ward of the covered military member, or a

Child for whom the covered military member stands in loco parentis, who is either under age 18, or age

18 or older and incapable of self-care because of a mental or physical disability at the time that FMLA

Leave is to commence, when such meetings are necessary due to circumstances arising from the active

duty or call to active duty status of a covered military member;

4. Financial and legal arrangements.

a. To make or update financial or legal arrangements to address the covered military member’s absence

while on active duty or call to active duty status, such as preparing and executing financial and

healthcare powers of attorney, transferring bank account signature authority, enrolling in the Defense

Enrollment Eligibility Reporting System (DEERS), obtaining military identification cards, or preparing

or updating a will or living trust; and

b. To act as the covered military member’s representative before a Federal, State, or local agency for

purposes of obtaining, arranging, or appealing military service benefits while the covered military

member is on active duty or call to active duty status, and for a period of 90 days following the

termination of the covered military member’s active duty status;

5. Counseling. To attend counseling provided by someone other than a health care Provider for oneself, for

the covered military member, or for the biological, adopted, or foster Child, a stepchild, or a legal ward of

the covered military member, or a Child for whom the covered military member stands in loco parentis, who

is either under age 18, or age 18 or older and incapable of self-care because of a mental or physical

disability at the time that FMLA Leave is to commence, provided that the need for counseling arises from

the active duty or call to active duty status of a covered military member;

6. Rest and recuperation. To spend time with a covered military member who is on short-term, temporary, rest

and recuperation leave during the period of deployment. Eligible Employees may take up to five days of

leave for each instance of rest and recuperation;

7. Post-deployment activities.

a. To attend arrival ceremonies, reintegration briefings and events, and any other official ceremony or

program sponsored by the military for a period of 90 days following the termination of the covered

military member’s active duty status; and

b. To address issues that arise from the death of a covered military member while on active duty status,

such as meeting and recovering the body of the covered military member and making funeral

arrangements; and

8. Additional activities. To address other events which arise out of the covered military member’s active duty

or call to active duty status provided that the Participating Employer and Employee agree that such leave

shall qualify as an exigency, and agree to both the timing and duration of such leave.

“Serious Health Condition”

“Serious Health Condition” shall mean an Illness, Injury, impairment, or physical or mental condition that involves:

1. Inpatient care in a Hospital, hospice, or residential medical facility; or

2. Continuing treatment by a health care Provider (a doctor of medicine or osteopathy who is authorized to

practice medicine or Surgery, as appropriate, by the State in which the doctor practices, or any other person

determined by the Secretary of Labor to be capable of providing health care services).

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“Serious Illness or Injury”

“Serious Illness or Injury” shall mean an Illness or Injury Incurred in the line of duty that may render the service

member medically unfit to perform his or her military duties.

“Son or Daughter”

“Son or Daughter” shall mean the Employee’s biological child, adopted child, stepchild, foster child, a child placed

in the Employee’s legal custody, or a child for which the Employee is acting as the parent in place of the child’s

natural blood related parent.

“Spouse”

“Spouse” shall mean an Employee’s husband or wife.

NOTE: For complete information regarding FMLA rights, contact the Participating Employer.

7.03 Continuation During USERRA

Participants who are absent from employment because they are in the Uniformed Services may elect to continue their

coverage under this Plan for up to 24 months. If a Participant elected to continue coverage under USERRA before

December 10, 2004, the maximum period for continuing coverage is 18 months. To continue coverage, Participants

must comply with the terms of the Plan, including election during the Plan’s annual enrollment period, and pay their

contributions, if any. In addition, USERRA also requires that, regardless of whether a Participant elected to continue

his or her coverage under the Plan, his or her coverage and his or her dependents’ coverage be reinstated

immediately upon his or her return to employment, so long as he or she meets certain requirements contained in

USERRA. Participants should contact their participating employer for information concerning their eligibility for

USERRA and any requirements of the Plan.

7.04 Continuation During COBRA – Introduction

The right to this form of continued coverage was created by a Federal law, under the Consolidated Omnibus Budget

Reconciliation Act of 1985, as amended (“COBRA”). COBRA Continuation Coverage can become available to

Participants when they otherwise would lose their group health coverage. It also can become available to other

members of the Participants family who are covered under the Plan when they otherwise would lose their group

health coverage. The entire cost (plus a reasonable administration fee) must be paid by the person. Coverage will

end in certain instances, including if the Participant or their covered dependents fail to make timely payment of

contributions or premiums. Participants should check with their employer to see if COBRA applies to them and/or

their covered dependents.

7.04A COBRA Continuation Coverage

“COBRA Continuation Coverage” is a continuation of Plan coverage when coverage otherwise would end because

of a life event known as a “Qualifying Event.” Life insurance, accidental death and dismemberment benefits and

weekly income or long-term disability benefits (if a part of the employer’s plan) are not considered for continuation

under COBRA.

7.04B Qualifying Events

Specific Qualifying Events are listed below. After a Qualifying Event, COBRA Continuation Coverage must be

offered to each person who is a “Qualified Plan Participant.” The Employee, the Employee’s spouse, and the

Employee’s dependent children could become Qualified Plan Participants if coverage under the Plan is lost because

of the Qualifying Event.

A covered Employee (meaning an employee covered under the Plan) will become a Qualified Plan Participant if he

or she loses his or her coverage under the Plan because either one of the following Qualifying Events happens:

1. The hours of employment are reduced; or

2. The employment ends for any reason other than gross misconduct.

The spouse of a covered Employee will become a Qualified Plan Participant if he or she loses his or her coverage

under the Plan because any of the following Qualifying Events happens:

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1. The spouse dies;

2. The spouse’s hours of employment are reduced;

3. The spouse’s employment ends for any reason other than his or her gross misconduct;

4. The spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

5. The spouse becomes divorced or legally separated from his or her spouse.

Dependent children will become Qualified Plan Participants if they lose coverage under the Plan because any of the

following Qualifying Events happens:

1. The parent-covered Employee dies;

2. The parent-covered Employee’s hours of employment are reduced;

3. The parent-covered Employee’s employment ends for any reason other than his or her gross misconduct;

4. The parent-covered Employee becomes entitled to Medicare benefits (Part A, Part B, or both);

5. The parents become divorced or legally separated; or

6. The child stops being eligible for coverage under the Plan as a Dependent Child.

If a proceeding in bankruptcy is filed with respect to Perry County, and that bankruptcy results in the loss of

coverage of any retired employee, spouse, surviving spouse, and Dependent Children covered under the Plan, such

member will become a Qualified Plan Participant with respect to the bankruptcy.

7.04C Employer Notice of Qualifying Events

When the Qualifying Event is the end of employment (for reasons other than gross misconduct), reduction of hours

of employment, death of the covered Employee, commencement of a proceeding in bankruptcy with respect to the

Employer, or the covered Employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), the

Employer must notify the Plan Administrator of the Qualifying Event.

7.04D Employee Notice of Qualifying Events

Each covered Employee or Qualified Plan Participant is responsible for providing the Plan Administrator with the

following notices, in writing, either by U.S. First Class Mail or hand delivery:

1. Notice of the occurrence of a Qualifying Event that is a divorce or legal separation of a covered Employee

(or former employee) from his or her spouse;

2. Notice of the occurrence of a Qualifying Event that is an individual’s ceasing to be eligible as a Dependent

Child under the terms of the Plan;

3. Notice of the occurrence of a second Qualifying Event after a Qualified Plan Participant has become

entitled to COBRA Continuation Coverage with a maximum duration of 18 (or 29) months;

4. Notice that a Qualified Plan Participant entitled to receive Continuation Coverage with a maximum duration

of 18 months has been determined by the Social Security Administration (“SSA”) to be disabled at any time

during the first 60 days of Continuation Coverage; and

5. Notice that a Qualified Plan Participant, with respect to whom a notice described above has been provided,

has subsequently been determined by the SSA to no longer be disabled.

The Plan Administrator is:

Perry County

Plan Administrator



740-432-9224

A form of notice is available, free of charge, from the Plan Administrator and must be used when providing the

notice.

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7.04E Deadline for providing the notice

For Qualifying Events described above, the notice must be furnished by the date that is 60 days after the latest of:

1. The date on which the relevant Qualifying Event occurs;

2. The date on which the Qualified Plan Participant loses (or would lose) coverage under the Plan as a result

of the Qualifying Event; or

3. The date on which the Qualified Plan Participant is informed, through the furnishing of the Plan’s SPD or

the general notice, of both the responsibility to provide the notice and the Plan’s procedures for providing

such notice to the Plan Administrator.

For the disability determination described above, the notice must be furnished by the date that is 60 days after the

latest of:

1. The date of the disability determination by the SSA;

2. The date on which a Qualifying Event occurs;

3. The date on which the Qualified Plan Participant loses (or would lose) coverage under the Plan as a result

of the Qualifying Event; or




In any event, this notice must be furnished before the end of the first 18 months of Continuation Coverage.

For a change in disability status described above, the notice must be furnished by the date that is 30 days after the

later of:

1. The date of the final determination by the SSA that the Qualified Plan Participant is no longer disabled; or




The notice must be postmarked (if mailed), or received by the Plan Administrator (if hand delivered), by the

deadline set forth above. If the notice is late, the opportunity to elect or extend COBRA Continuation Coverage is

lost, and if the person is electing COBRA Continuation Coverage, his or her coverage under the Plan will

terminate on the last date for which he or she is eligible under the terms of the Plan, or if the person is extending

COBRA Continuation Coverage, such Coverage will end on the last day of the initial 18-month COBRA coverage

period.

7.04F Who Can Provide the Notice

Any individual who is the covered Employee (or former employee), a Qualified Plan Participant with respect to the

Qualifying Event, or any representative acting on behalf of the covered Employee (or former employee) or Qualified

Plan Participant, may provide the notice, and the provision of notice by one individual shall satisfy any responsibility

to provide notice on behalf of all related Qualified Plan Participants with respect to the Qualifying Event.

7.04G Required Contents of the Notice

The notice must contain the following information:

1. Name and address of the covered Employee or former employee;

2. Identification of the initial Qualifying Event and its date of occurrence, if the person is already receiving

COBRA Continuation Coverage and wishes to extend the maximum coverage period;

3. A description of the Qualifying Event (for example, divorce, legal separation, cessation of dependent status,

entitlement to Medicare by the covered Employee or former employee, death of the covered Employee or

former employee, disability of a Qualified Plan Participant or loss of disability status);

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4. In the case of a Qualifying Event that is divorce or legal separation, name(s) and address(es) of spouse and

dependent child(ren) covered under the Plan, date of divorce or legal separation, and a copy of the decree of

divorce or legal separation;

5. In the case of a Qualifying Event that is Medicare entitlement of the covered Employee or former employee,

date of entitlement, and name(s) and address(es) of spouse and Dependent child(ren) covered under the

Plan;

6. In the case of a Qualifying Event that is a Dependent Child’s cessation of Dependent status under the Plan,

name and address of the Child, reason the Child ceased to be an eligible Dependent (for example, attained

limiting age, lost student status, married or other);

7. In the case of a Qualifying Event that is the death of the covered Employee or former employee, the date of

death, and name(s) and address(es) of spouse and Dependent Child(ren) covered under the Plan;

8. In the case of a Qualifying Event that is disability of a Qualified Plan Participant, name and address of the

disabled Qualified Plan Participant, name(s) and address(es) of other family members covered under the

Plan, the date the disability began, the date of the SSA’s determination, and a copy of the SSA’s

determination;

9. In the case of a Qualifying Event that is loss of disability status, name and address of the Qualified Plan

Participant who is no longer disabled, name(s) and address(es) of other family members covered under the

Plan, the date the disability ended and the date of the SSA’s determination; and

10. A certification that the information is true and correct, a signature and date.

If a copy of the decree of divorce or legal separation or the SSA’s determination cannot be provided by the deadline

for providing the notice, complete and provide the notice, as instructed, by the deadline and submit the copy of the

decree of divorce or legal separation or the SSA’s determination within 30 days after the deadline. The notice will

be timely if done so. However, no COBRA Continuation Coverage, or extension of such Coverage, will be available

until the copy of the decree of divorce or legal separation or the SSA’s determination is provided.

If the notice does not contain all of the required information, the Plan Administrator may request additional

information. If the individual fails to provide such information within the time period specified by the Plan

Administrator in the request, the Plan Administrator may reject the notice if it does not contain enough information

for the Plan Administrator to identify the plan, the covered Employee (or former employee), the Qualified Plan

Participants, the Qualifying Event or disability, and the date on which the Qualifying Event, if any, occurred.

7.04H Electing COBRA Continuation Coverage

Complete instructions on how to elect COBRA Continuation Coverage will be provided by the Plan Administrator

within 14 days of receiving the notice of the Qualifying Event. The individual then has 60 days in which to elect

COBRA Continuation Coverage. The 60-day period is measured from the later of the date coverage terminates and

the date of the notice containing the instructions. If COBRA Continuation Coverage is not elected in that 60-day

period, then the right to elect it ceases.

Each Qualified Plan Participant will have an independent right to elect COBRA Continuation Coverage. Covered

Employees may elect COBRA Continuation Coverage on behalf of their spouses, and parents may elect COBRA

Continuation Coverage on behalf of their children.

In the event that the Plan Administrator determines that the individual is not entitled to COBRA Continuation

Coverage, the Plan Administrator will provide to the individual an explanation as to why he or she is not entitled to

COBRA Continuation Coverage.

7.04I Duration of COBRA Continuation Coverage

COBRA Continuation Coverage will be available up to the maximum time period shown below. Generally, multiple

Qualifying Events which may be combined under COBRA will not continue coverage for more than 36 months

beyond the date of the original Qualifying Event. When the Qualifying Event is “entitlement to Medicare,” the

36-month continuation period is measured from the date of the original Qualifying Event. For all other Qualifying

Events, the continuation period is measured from the date of the Qualifying Event, not the date of loss of coverage.

When the Qualifying Event is the death of the covered Employee (or former employee), the covered Employee’s (or

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former employee’s) becoming entitled to Medicare benefits (under Part A, Part B, or both), a divorce or legal

separation, or a Dependent Child’s losing eligibility as a Dependent Child, COBRA Continuation Coverage lasts for

up to a total of 36 months.

When the Qualifying Event is the end of employment or reduction of the covered Employee’s hours of employment,

and the covered Employee became entitled to Medicare benefits less than 18 months before the Qualifying Event,

COBRA Continuation Coverage for Qualified Plan Participants other than the covered Employee lasts until 36

months after the date of Medicare entitlement. For example, if a covered Employee becomes entitled to Medicare

eight months before the date on which his or her employment terminates, COBRA Continuation Coverage for his or

her spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months

after the date of the Qualifying Event (36 months minus 8 months).

Otherwise, when the Qualifying Event is the end of employment (for reasons other than gross misconduct) or

reduction of the covered Employee’s hours of employment, COBRA Continuation Coverage generally lasts for only

up to a total of 18 months. There are two ways in which this 18-month period of COBRA Continuation Coverage

can be extended.

7.04J Disability Extension of COBRA Continuation Coverage

If an Employee or anyone in an Employee’s family covered under the Plan is determined by the SSA to be disabled

and the Employee notifies the Plan Administrator as set forth above, the Employee and his or her entire family may

be entitled to receive up to an additional 11 months of COBRA Continuation Coverage, for a total maximum of 29

months. The disability would have to have started at some time before the 60th

day of COBRA Continuation

Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage. An extra

fee will be charged for this extended COBRA Continuation Coverage.

7.04K Second Qualifying Event Extension of COBRA Continuation Coverage

If an Employee’s family experiences another Qualifying Event while receiving 18 months of COBRA Continuation

Coverage, the spouse and Dependent Children in the family can get up to 18 additional months of COBRA

Continuation Coverage, for a maximum of 36 months, if notice of the second Qualifying Event properly is given to

the Plan as set forth above. This extension may be available to the spouse and any Dependent Children receiving

COBRA Continuation Coverage if the covered Employee or former employee dies, becomes entitled to Medicare

benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the Dependent Child stops being

eligible under the Plan as a Dependent Child, but only if the event would have caused the spouse or Dependent Child

to lose coverage under the Plan had the first Qualifying Event not occurred.

7.04L Shorter Duration of COBRA Continuation Coverage

COBRA Continuation Coverage also may end before the end of the maximum period on the earliest of the following

dates:

1. The date the employer ceases to provide a group health plan to any employee;

2. The date on which coverage ceases by reason of the Qualified Plan Participant’s failure to make timely

payment of any required contributions or premium;

3. The date that the Qualified Plan Participant first becomes, after the date of election, covered under any

other group health plan (as an employee or otherwise), or entitled to either Medicare Part A or Part B

(whichever comes first) except as stated under COBRA’s special bankruptcy rules. However, a Qualified

Plan Participant who becomes covered under a group health plan which has a pre-existing condition limit

must be allowed to continue COBRA Continuation Coverage for the length of a pre-existing condition or to

the COBRA maximum time period, if less; or

4. The first day of the month that begins more than 30 days after the date of the SSA’s determination that the

Qualified Plan Participant is no longer disabled, but in no event before the end of the maximum coverage

period that applied without taking into consideration the disability extension.

7.04M Contribution and/or Premium Requirements

Once COBRA Continuation Coverage is elected, the individual must pay for the cost of the initial period of coverage

within 45 days. Payments then are due on the first day of each month to continue coverage for that month. If a

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payment is not received within 30 days of the due date, COBRA Continuation Coverage will be canceled and will

not be reinstated.

7.04N Special COBRA Contribution and/or Premium Assistance Opportunity

The Federal Government through the passage of the “American Recovery and Reinvestment Act of 2009” and the

“Department of Defense Appropriations Act, 2010” has made a special COBRA opportunity available for certain

Assistance Eligible Individuals.

7.04O Reduced COBRA Contribution and/or Premium

For a period not to exceed 15 months, an Assistance Eligible Individual is treated as having paid any contribution or

premium required for COBRA continuation coverage under the Plan if the individual pays 35% of the contribution or

premium. Thus, if the Assistance Eligible Individual pays 35% of the contribution or premium, the Plan will treat the

individual as having paid the full contribution or premium required for COBRA continuation coverage, and the

individual is entitled to a subsidy for 65% of the contribution or premium.

7.04P Termination of Eligibility for Contribution and/or Premium Assistance

The Assistance Eligible Individual’s eligibility for the subsidy terminates with the first month beginning on or after

the earlier of:

1. The date which is 15 months after the first day of the first month for which the subsidy applies;

2. The end of the maximum required period of continuation coverage for the qualified Plan Participant under

the Code’s COBRA rules or the relevant State or Federal law (or regulation); or

3. The date that the Assistance Eligible Individual becomes eligible for Medicare benefits under Title XVIII of the

Social Security Act or health coverage under another group health plan (including, for example, a group

health plan maintained by the new employer of the individual or a plan maintained by the employer of the

individual’s spouse).

However, eligibility for coverage under another group health plan does not terminate eligibility for the subsidy if

the other group health plan provides only dental, vision, counseling, or referral services (or a combination of the

foregoing), is a health flexible spending account or health reimbursement arrangement, or is coverage for treatment

that is furnished in an on-site medical facility maintained by the employer and that consists primarily of first-aid services,

prevention and wellness care, or similar care (or a combination of such care).

If a Qualified Plan Participant paying a reduced contribution or premium for COBRA continuation coverage

under this provision becomes eligible for coverage under another group health plan or Medicare, then the

Qualified Plan Participant is required to notify the Plan in writing. This notification must be provided to the Plan

in the time and manner as is specified by the Secretary of Labor. If an Assistance Eligible Individual fails to

provide this notification at the required time and in the required manner, and as a result the individual’s COBRA

continuation coverage continues to be subsidized after the termination of the individual’s eligibility for such subsidy, a

penalty will be imposed by the Department of Labor that is equal to 110% of the subsidy provided after

termination of eligibility.

7.04Q Second COBRA Election Opportunity

The American Recovery and Reinvestment Act of 2009 provides a special 60 day election period for a Qualified Plan

Participant who is eligible for a reduced contribution or premium and who has not elected COBRA continuation coverage

as of the date of enactment. The 60 day election period begins on the date the notice is provided to the Qualified Plan

Participant of the special election period. However, this special election period does not extend the period of COBRA

continuation coverage beyond the original maximum required period and any COBRA continuation coverage elected

pursuant to this special election period begins on the date of enactment and does not include any period prior to that

date. Thus, for example, if a covered Employee involuntarily terminated employment on September 10, 2008, but did not

elect COBRA continuation coverage and was not eligible for coverage under another group health plan, the Employee

would have 60 days after date of notification of this new election right to elect the coverage and receive the subsidy.

If the Employee made the election, the coverage would begin February 17, 2009, and does not include any period prior to

that date. However, the coverage would not be required to last for 18 months. Instead the maximum required COBRA

continuation coverage period would end no later than 18 months after September 10, 2008.

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7.04R Election to Pay Contribution and/or Premiums Retroactively and Maintain COBRA Coverage

The Department of Defense Appropriations Act, 2010 allows Assistance Eligible Individuals the opportunity to

retroactively pay contribution or premiums to maintain coverage under the COBRA subsidy. These individuals shall

be treated as having timely paid their COBRA contribution or premiums, when:

1. The Assistance Eligible Individual was covered under the COBRA continuation subsidy immediately

preceding the enactment of the Department of Defense Appropriations Act, 2010; and

2. The Assistance Eligible Individual pays such contribution or premiums no later than February 17, 2010 (60

days after the enactment date of the Department of Defense Appropriations Act, 2010, on December 19,

2009).

7.05 Additional Information

Additional information about the Plan and COBRA Continuation Coverage is available from the Plan Administrator,

who is:

Perry County

Plan Administrator



740-432-9224

7.06 Current Addresses

In order to protect the rights of the Employee’s family, the Employee should keep the Plan Administrator (who is

identified above) informed of any changes in the addresses of family members.

7.07 The Trade Act of 2002

Two provisions under the Trade Act of 2002 (the “Trade Act”) affect the benefits received under COBRA. First,

certain eligible individuals who lose their jobs due to international trade agreements may receive a 65% tax credit for

premiums paid for certain types of health insurance, including COBRA contribution or premiums. Second, eligible

individuals under the Trade Act who do not elect COBRA continuation within the election period will be allowed an

additional 60-day period to elect COBRA continuation coverage. If the qualified Plan Participant elects continuation

during this second election period, the coverage period will run from the beginning date of the second election

period. You should consult the Plan Administrator if you believe the Trade Act applies to you.

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ARTICLE VIII

GENERAL LIMITATIONS AND EXCLUSIONS

This section applies to all benefits provided under any section of this Plan. This Plan does not cover any charge for

care, supplies, treatment, and/or services:

Alcohol. To a Plan Participant, arising from taking part in any activity made illegal due to the use of alcohol.

Expenses will be covered for Injured Plan Participants other than the person partaking in an activity made illegal due

to the use of alcohol, and expenses may be covered for Substance Abuse treatment as specified in this Plan, if

applicable. This exclusion does not apply (a) if the injury resulted from being the victim of an act of domestic

violence, or (b) resulted from a medical condition (including both physical and mental health conditions);

Custodial Care. That do not restore health, unless specifically mentioned otherwise;

Deductible Applicable. That are not payable due to the application of any specified Deductible provisions

contained herein;

Error. That are required to treat injuries that are sustained or an illness that is contracted, including infections and

complications, while the Plan Participant was under, and due to, the care of a Provider wherein such illness, injury,

infection or complication is not reasonably expected to occur. This exclusion will apply to expenses directly or

indirectly resulting from the circumstances of the course of treatment that, in the opinion of the Plan Administrator,

in its sole discretion, unreasonably gave rise to the expense;

Excess. That are not payable under the Plan due to application of any Plan maximum or limit or because the

charges are in excess of the Usual and Customary amount, or are for services not deemed to be Reasonable or

Medically Necessary, based upon the Plan Administrator’s determination as set forth by and within the terms of this

document;

Experimental. That are Experimental or Investigational;

Family Member. That are performed by a person who is related to the Participant as a spouse, parent, child, brother

or sister, whether the relationship exists by virtue of “blood” or “in law”;

Government. That are expenses to the extent paid, or which the Participant is entitled to have paid or obtain

without cost, in accordance with the laws or regulations of any government;

Hazardous Pursuit, Hobby or Activity. Of an injury or sickness that results from engaging in a hazardous pursuit,

hobby or activity. A pursuit, hobby or activity is hazardous if it involves or exposes an individual to risk of a degree

or nature not customarily undertaken in the course of the Plan Participant’s customary occupation or if it involves

leisure time activities commonly considered as involving unusual or exceptional risks, characterized by a constant

threat of danger or risk of bodily harm including but not limited to: hang gliding, skydiving, bungee jumping, water

skiing, snow skiing, jet ski operation, horseback riding, boating, parasailing, use of all terrain vehicles, rock

climbing, use of explosives, automobile, motorcycle, aircraft, or speed boat racing, reckless operation of a vehicle or

other machinery, and travel to countries with advisory warnings;

Illegal acts. For services and supplies incurred as a result of an Illness or Injury, caused by or contributed to by

engaging in an illegal act, by committing or attempting to commit a crime or by participating in a riot or public

disturbance;

Incurred by Other Persons. For expenses actually incurred by other persons;

Medical Necessity. That are not Medically Necessary;

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Medicare. For benefits that are provided, or which would have been provided had the Participant enrolled, applied

for, or maintained eligibility for such care and service benefits, under Title XVIII of the Federal Social Security Act

of 1965 (Medicare), including any amendments thereto, or under any Federal law or regulation, except as provided

in the sections entitled “Coordination of Benefits” and “Medicare;”

Negligence. For Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the

part of any licensed Physician;

No Legal Obligation. That are provided to a Participant for which the Provider of a service customarily makes no

direct charge, or for which the Participant is not legally obligated to pay, or for which no charges would be made in

the absence of this coverage, including but not limited to fees, care, supplies, or services for which a person,

company or any other entity except the Participant or this benefit plan, may be liable for necessitating the fees, care,

supplies, or services;

Not Acceptable. That are not accepted as standard practice by the AMA, ADA, or the Food and Drug

Administration;

Not Actually Rendered. That are not actually rendered;

Not Specifically Covered. That are not specifically covered under this Plan;

Other than Attending Physician. Other than those certified by a Physician who is attending the Participant as

being required for the treatment of Injury or Disease, and performed by an appropriate Provider;

Participant Liability Waived. For charges in connection with a claim where the Participant does not meet his or

her cost-sharing responsibility (i.e. copay, deductible or coinsurance). This exclusion applies regardless of whether

the Provider charges or attempts to collect the Participant's cost-sharing responsibility.

Prior to Coverage. That are rendered or received prior to or after any period of coverage hereunder, except as

specifically provided herein;

Prohibited by Law. To the extent that payment under this Plan is prohibited by law;

Provider Error. Required as a result of unreasonable provider error;

Self-inflicted. That are the result of intentionally self-inflicted Injuries or Illnesses. This exclusion does not apply

(a) if the injury resulted from being the victim of an act of domestic violence, or (b) resulted from a medical

condition (including both physical and mental health conditions);

Subrogation, Reimbursement, and/or Third Party Responsibility. Of an Injury or Sickness not payable by virtue

of the Plan’s subrogation, reimbursement, and/or third party responsibility provisions; and

War. Incurred as a result of war or any act of war, whether declared or undeclared, or any act of aggression, when

the Participant is a member of the armed forces of any Country, or during service by a Participant in the armed forces

of any Country. This exclusion does not apply to any Participant who is not a member of the armed forces.

With respect to any Injury which is otherwise covered by the Plan, the Plan will not deny benefits otherwise

provided for treatment of the Injury if the Injury results from an act of domestic violence or a medical condition.

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ARTICLE IX

PLAN ADMINISTRATION

The Plan is administered by the Plan Administrator. The Plan Administrator has retained the services of the Third

Party Administrator to provide certain claims processing and other technical services.

9.01 Plan Administrator

The Plan is administered by the Plan Administrator in accordance with these provisions. An individual or entity may

be appointed by the Plan Sponsor to be Plan Administrator and serve at the convenience of the Plan Sponsor. If the

Plan Administrator resigns, dies, is otherwise unable to perform, is dissolved, or is removed from the position, the

Plan Sponsor shall appoint a new Plan Administrator as soon as reasonably possible.

The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies,

interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have

maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make

determinations regarding issues which relate to eligibility for benefits (including the determination of what services,

supplies, care and treatments are Experimental), to decide disputes which may arise relative to a Participant’s rights,

and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the Plan

Administrator as to the facts related to any claim for benefits and the meaning and intent of any provision of the Plan,

or its application to any claim, shall receive the maximum deference provided by law and will be final and binding

on all interested parties. Benefits under this Plan will be paid only if the Plan Administrator decides, in its

discretion, that the Participant is entitled to them.

9.02 Duties of the Plan Administrator

The duties of the Plan Administrator include the following:

1. To administer the Plan in accordance with its terms;

2. To determine all questions of eligibility, status and coverage under the Plan;

3. To interpret the Plan, including the authority to construe possible ambiguities, inconsistencies, omissions

and disputed terms;

4. To make factual findings;

5. To decide disputes which may arise relative to a Participant’s rights and/or availability of benefits;

6. To prescribe procedures for filing a claim for benefits, to review claim denials and appeals relating to them

and to uphold or reverse such denials;

7. To keep and maintain the Plan documents and all other records pertaining to the Plan;

8. To appoint and supervise a third party administrator to pay claims;

9. To perform all necessary reporting;

10. To establish and communicate procedures to determine whether a medical child support order is a QMCSO;

11. To delegate to any person or entity such powers, duties and responsibilities as it deems appropriate; and

12. To perform each and every function necessary for or related to the Plan’s administration.

9.03 Amending and Terminating the Plan

The Plan Sponsor expects to maintain this Plan indefinitely; however, as the settlor of the Plan, the Plan Sponsor,

through its directors and officers, may, in its sole discretion, at any time, amend, suspend or terminate the Plan in

whole or in part. This includes amending the benefits under the Plan or the Trust Agreement (if any). This includes

amending the benefits under the Plan.

Any such amendment, suspension or termination shall be enacted, if the Plan Sponsor is a corporation, by resolution

of the Plan Sponsor’s directors and officers, which shall be acted upon as provided in the Plan Sponsor’s Articles of

Incorporation or Bylaws, as applicable, and in accordance with applicable Federal and State law. Notice shall be

provided as required. In the event that the Plan Sponsor is a different type of entity, then such amendment,

suspension or termination shall be taken and enacted in accordance with applicable Federal and State law and any

applicable governing documents. In the event that the Plan Sponsor is a sole proprietorship, then such action shall

be taken by the sole proprietor, in his or her own discretion.

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If the Plan is terminated, the rights of the Participants are limited to expenses incurred before termination. All

amendments to this Plan shall become effective as of a date established by the Plan Sponsor.

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ARTICLE X

CLAIM PROCEDURES; PAYMENT OF CLAIMS

The procedures outlined below must be followed by Participants to obtain payment of health benefits under this Plan.

10.01 Health Claims

All claims and questions regarding health claims should be directed to the Third Party Administrator. The Plan

Administrator shall be ultimately and finally responsible for adjudicating such claims and for providing full and fair

review of the decision on such claims in accordance with the following provisions. Benefits under the Plan will be

paid only if the Plan Administrator decides in its discretion that the Participant is entitled to them. The responsibility

to process claims in accordance with the Plan Document may be delegated to the Third Party Administrator;

provided, however, that the Third Party Administrator is not a fiduciary of the Plan and does not have the authority

to make decisions involving the use of discretion.

Each Participant claiming benefits under the Plan shall be responsible for supplying, at such times and in such

manner as the Plan Administrator in its sole discretion may require, written proof that the expenses were incurred or

that the benefit is covered under the Plan. If the Plan Administrator in its sole discretion shall determine that the

Participant has not incurred a covered expense or that the benefit is not covered under the Plan, or if the Participant

shall fail to furnish such proof as is requested, no benefits shall be payable under the Plan.

A call from a Provider who wants to know if an individual is covered under the Plan, or if a certain procedure is

covered by the Plan, prior to providing treatment is not a “claim,” since an actual claim for benefits is not being filed

with the Plan. These are simply requests for information, and any response is not a guarantee of benefits, since

payment of benefits is subject to all Plan provisions, limitations and exclusions. Once treatment is rendered, a

Clean Claim must be filed with the Plan (which will be a “Post-service Claim”). At that time, a determination will be

made as to what benefits are payable under the Plan.

A Participant has the right to request a review of an Adverse Benefit Determination. If the claim is denied at the end

of the appeal process, as described below, the Plan's final decision is known as a final Adverse Benefit

Determination. If the Participant receives notice of a final Adverse Benefit Determination, or if the Plan does not

follow the claims procedures properly, the Participant then has the right to request an independent external review.

The external review procedures are described below.

The claims procedures are intended to provide a full and fair review. This means, among other things, that claims

and appeals will be decided in a manner designed to ensure the independence and impartiality of the persons

involved in making these decisions.

Benefits will be payable to a Plan Participant, or to a Provider that has accepted an assignment of benefits as

consideration in full for services rendered.

According to Federal regulations which apply to the Plan, there are four types of claims: Pre-service (Urgent and

Non-urgent), Concurrent Care and Post-service.

Pre-service Claims. A “pre-service claim” is a claim for a benefit under the Plan where the Plan conditions

receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

A “pre-service urgent care claim” is any claim for medical care or treatment with respect to which the

application of the time periods for making non-urgent care determinations could seriously jeopardize the

life or health of the Participant or the Participant’s ability to regain maximum function, or, in the opinion of

a physician with knowledge of the Participant’s medical condition, would subject the Participant to severe

pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

If the Plan does not require the Participant to obtain approval of a specific medical service prior to getting

treatment, then there is no pre-service claim. The Participant simply follows the Plan’s procedures with

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respect to any notice which may be required after receipt of treatment, and files the claim as a post-service

claim.

Concurrent Claims. A “concurrent claim” arises when the Plan has approved an on-going course of

treatment to be provided over a period of time or number of treatments, and either:

The Plan Administrator determines that the course of treatment should be reduced or terminated; or

The Participant requests extension of the course of treatment beyond that which the Plan Administrator

has approved.

If the Plan does not require the Participant to obtain approval of a medical service prior to getting treatment,

then there is no need to contact the Plan Administrator to request an extension of a course of treatment. The

Participant simply follows the Plan’s procedures with respect to any notice which may be required after

receipt of treatment, and files the claim as a post-service claim.

Post-service Claims. A “post-service claim” is a claim for a benefit under the Plan after the services have

been rendered.

10.01A When Health Claims Must Be Filed

Post-service health claims must be filed with the Third Party Administrator within 15 months of the date charges for

the service were incurred. Benefits are based upon the Plan’s provisions at the time the charges were incurred.

Claims filed later than that date shall be denied.

A pre-service claim (including a concurrent claim that also is a pre-service claim) is considered to be filed when the

request for approval of treatment or services is made and received by the Third Party Administrator in accordance

with the Plan’s procedures.

Upon receipt of the required information, the claim will be deemed to be filed with the Plan. The Third Party

Administrator will determine if enough information has been submitted to enable proper consideration of the claim.

If not, more information may be requested as provided herein. This additional information must be received by the

Third Party Administrator within 45 days from receipt by the Participant of the request for additional information.

Failure to do so may result in claims being declined or reduced.

10.01B Timing of Claim Decisions

The Plan Administrator shall notify the Participant, in accordance with the provisions set forth below, of any

Adverse Benefit Determination (and, in the case of pre-service claims and concurrent claims, of decisions that a

claim is payable in full) within the following timeframes:

Pre-service Urgent Care Claims:

If the Participant has provided all of the necessary information, as soon as possible, taking into account

the medical exigencies, but not later than 72 hours after receipt of the claim.

If the Participant has not provided all of the information needed to process the claim, then the

Participant will be notified as to what specific information is needed as soon as possible, but not later

than 72 hours after receipt of the claim.

The Participant will be notified of a determination of benefits as soon as possible, but not later than 72

hours, taking into account the medical exigencies, after the earliest of:

º The Plan’s receipt of the specified information; or

º The end of the period afforded the Participant to provide the information.

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If there is an Adverse Benefit Determination, a request for an expedited appeal may be submitted orally

or in writing by the Participant. All necessary information, including the Plan’s benefit determination

on review, may be transmitted between the Plan and the Participant by telephone, facsimile, or other

similarly expeditious method. Alternatively, the Participant may request an expedited review under the

external review process.

Pre-service Non-urgent Care Claims:

If the Participant has provided all of the information needed to process the claim, in a reasonable

period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the

claim, unless an extension has been requested, then prior to the end of the 15-day extension period.

If the Participant has not provided all of the information needed to process the claim, then the

Participant will be notified as to what specific information is needed as soon as possible, but not later

than 5 days after receipt of the claim. The Participant will be notified of a determination of benefits in

a reasonable period of time appropriate to the medical circumstances, either prior to the end of the

extension period (if additional information was requested during the initial processing period), or by

the date agreed to by the Plan Administrator and the Participant (if additional information was

requested during the extension period).

Concurrent Claims:

Plan Notice of Reduction or Termination. If the Plan Administrator is notifying the Participant of a

reduction or termination of a course of treatment (other than by Plan amendment or termination),

before the end of such period of time or number of treatments. The Participant will be notified

sufficiently in advance of the reduction or termination to allow the Participant to appeal and obtain a

determination on review of that Adverse Benefit Determination before the benefit is reduced or

terminated. This rule does not apply if benefits are reduced or eliminated due to plan amendment or

termination. A similar process applies for claims based on a rescission of coverage for fraud or

misrepresentation.

Request by Participant Involving Urgent Care. If the Plan Administrator receives a request from a

Participant to extend the course of treatment beyond the period of time or number of treatments that is a

claim involving urgent care, as soon as possible, taking into account the medical exigencies, but not

later than 72 hours after receipt of the claim, as long as the Participant makes the request at least 72

hours prior to the expiration of the prescribed period of time or number of treatments. If the Participant

submits the request with less than 24 hours prior to the expiration of the prescribed period of time or

number of treatments, the request will be treated as a claim involving urgent care and decided within

the urgent care timeframe.

Request by Participant Involving Non-urgent Care. If the Plan Administrator receives a request from

the Participant to extend the course of treatment beyond the period of time or number of treatments that

is a claim not involving urgent care, the request will be treated as a new benefit claim and decided

within the timeframe appropriate to the type of claim (either as a pre-service non-urgent claim or a

post-service claim).

Request by Participant Involving Rescission. With respect to rescissions, the following timetable

applies:

º Notification to Participant 30 days

º Notification of Adverse Benefit Determination on appeal 30 days

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Post-service Claims:

If the Participant has provided all of the information needed to process the claim, in a reasonable

period of time, but not later than 30 days after receipt of the claim, unless an extension has been

requested, then prior to the end of the 15-day extension period.

If the Participant has not provided all of the information needed to process the claim and additional

information is requested during the initial processing period, then the Participant will be notified of a

determination of benefits prior to the end of the extension period, unless additional information is

requested during the extension period, then the Participant will be notified of the determination by a

date agreed to by the Plan Administrator and the Participant.

Extensions – Pre-service Urgent Care Claims. No extensions are available in connection with Pre-service

urgent care claims.

Extensions – Pre-service Non-urgent Care Claims. This period may be extended by the Plan for up to 15

days, provided that the Plan Administrator both determines that such an extension is necessary due to

matters beyond the control of the Plan and notifies the Participant, prior to the expiration of the initial 15-

day processing period, of the circumstances requiring the extension of time and the date by which the Plan

expects to render a decision.

Extensions – Post-service Claims. This period may be extended by the Plan for up to 15 days, provided that

the Plan Administrator both determines that such an extension is necessary due to matters beyond the

control of the Plan and notifies the Participant, prior to the expiration of the initial 30-day processing

period, of the circumstances requiring the extension of time and the date by which the Plan expects to

render a decision.

Calculating Time Periods. The period of time within which a benefit determination is required to be made

shall begin at the time a claim is deemed to be filed in accordance with the procedures of the Plan.

10.01C Notification of an Adverse Benefit Determination

The Plan Administrator shall provide a Participant with a notice, either in writing or electronically (or, in the case of

pre-service urgent care claims, by telephone, facsimile or similar method, with written or electronic notice). The

notice will contain the following information:

Information sufficient to allow the Participant to identify the claim involved (including date of service, the

healthcare provider, the claim amount, if applicable, and a statement describing the availability, upon

request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding

meaning);

A reference to the specific portion(s) of the plan provisions upon which a denial is based;

Specific reason(s) for a denial, including the denial code and its corresponding meaning, and a description

of the Plan’s standard, if any, that was used in denying the claim;

A description of any additional information necessary for the Participant to perfect the claim and an

explanation of why such information is necessary;

A description of the Plan’s internal appeals and external review processes and the time limits applicable to

the processes. This description will include information on how to initiate the appeal;

A statement that the Participant is entitled to receive, upon request and free of charge, reasonable access to,

and copies of, all documents, records and other information relevant to the Participant’s claim for benefits;

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The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did

not rely upon their advice (or a statement that the identity of the expert will be provided, upon request);

Any rule, guideline, protocol or similar criterion that was relied upon, considered, or generated in making

the determination will be provided free of charge. If this is not practical, a statement will be included that

such a rule, guideline, protocol or similar criterion was relied upon in making the determination and a copy

will be provided to the Participant, free of charge, upon request;

In the case of denials based upon a medical judgment (such as whether the treatment is medically necessary

or experimental), either an explanation of the scientific or clinical judgment for the determination, applying

the terms of the Plan to the Participant’s medical circumstances, will be provided. If this is not practical, a

statement will be included that such explanation will be provided to the Participant, free of charge, upon

request;

Information about the availability of, and contact information for, an applicable office of health insurance

consumer assistance or ombudsman established under applicable federal law to assist individuals with the

internal claims and appeals and external review processes; and

In a claim involving urgent care, a description of the Plan’s expedited review process.

10.02 Appeal of Adverse Benefit Determinations

10.02A Full and Fair Review of All Claims

In cases where a claim for benefits is denied, in whole or in part, and the Participant believes the claim has been

denied wrongly, the Participant may appeal the denial and review pertinent documents. The claims procedures of

this Plan provide a Participant with a reasonable opportunity for a full and fair review of a claim and Adverse

Benefit Determination. More specifically, the Plan provides:

Participants at least 180 days following receipt of a notification of an initial Adverse Benefit Determination

within which to appeal the determination;

Participants the opportunity to submit written comments, documents, records, and other information relating

to the claim for benefits;

For a review that does not afford deference to the previous Adverse Benefit Determination and that is

conducted by an appropriate named fiduciary of the Plan, who shall be neither the individual who made the

Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of such individual;

For a review that takes into account all comments, documents, records, and other information submitted by

the Participant relating to the claim, without regard to whether such information was submitted or

considered in any prior benefit determination;

That, in deciding an appeal of any Adverse Benefit Determination that is based in whole or in part upon a

medical judgment, the Plan fiduciary shall consult with a health care professional who has appropriate

training and experience in the field of medicine involved in the medical judgment, who is neither an

individual who was consulted in connection with the Adverse Benefit Determination that is the subject of

the appeal, nor the subordinate of any such individual;

For the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in

connection with a claim, even if the Plan did not rely upon their advice;

That a Participant will be provided, free of charge: (a) reasonable access to, and copies of, all documents,

records, and other information relevant to the Participant’s claim in possession of the Plan Administrator or

Third Party Administrator; (b) information regarding any voluntary appeals procedures offered by the Plan;

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(c) information regarding the Participant’s right to an external review process; (d) any internal rule,

guideline, protocol or other similar criterion relied upon, considered or generated in making the adverse

determination; and (e) an explanation of the scientific or clinical judgment for the determination, applying

the terms of the Plan to the Participant’s medical circumstances; and

That a Participant will be provided, free of charge, and sufficiently in advance of the date that the notice of

final internal Adverse Benefit Determination is required, with new or additional evidence considered, relied

upon, or generated by the Plan in connection with the Claim, as well as any new or additional rationale for a

denial at the internal appeals stage, and a reasonable opportunity for the Participant to respond to such new

evidence or rationale.

10.02B Requirements for Appeal

The Participant must file the appeal in writing (although oral appeals are permitted for pre-service urgent care

claims) within 180 days following receipt of the notice of an Adverse Benefit Determination. For pre-service urgent

care claims, if the Participant chooses to orally appeal, the Participant may telephone:

HealthSCOPE Benefits, Inc.

P.O. Box 2860


614-797-5351

To file an appeal in writing, the Participant’s appeal must be addressed as follows and mailed or faxed as follows:

HealthSCOPE Benefits, Inc.

P.O. Box 2860


614-797-5351

It shall be the responsibility of the Participant to submit proof that the claim for benefits is covered and payable

under the provisions of the Plan. Any appeal must include:

The name of the employee/Participant;

The employee/Participant’s social security number;

The group name or identification number;

All facts and theories supporting the claim for benefits. Failure to include any theories or facts in the

appeal will result in their being deemed waived. In other words, the Participant will lose the right to

raise factual arguments and theories which support this claim if the Participant fails to include them

in the appeal;

A statement in clear and concise terms of the reason or reasons for disagreement with the handling of the

claim; and

Any material or information that the Participant has which indicates that the Participant is entitled to

benefits under the Plan.

If the Participant provides all of the required information, it may be that the expenses will be eligible for

payment under the Plan.

10.02C Timing of Notification of Benefit Determination on Review

The Plan Administrator shall notify the Participant of the Plan’s benefit determination on review within the following

timeframes:

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Pre-service Urgent Care Claims: As soon as possible, taking into account the medical exigencies, but not

later than 72 hours after receipt of the appeal.

Pre-service Non-urgent Care Claims: Within a reasonable period of time appropriate to the medical

circumstances, but not later than 30 days after receipt of the appeal.

Concurrent Claims: The response will be made in the appropriate time period based upon the type of claim

– pre-service urgent, pre-service non-urgent or post-service.

Post-service Claims: Within a reasonable period of time, but not later than 60 days after receipt of the

appeal.

Calculating Time Periods. The period of time within which the Plan’s determination is required to be made

shall begin at the time an appeal is filed in accordance with the procedures of this Plan, without regard to

whether all information necessary to make the determination accompanies the filing.

10.02D Manner and Content of Notification of Adverse Benefit Determination on Review

The Plan Administrator shall provide a Participant with notification, with respect to pre-service urgent care claims,

by telephone, facsimile or similar method, and with respect to all other types of claims, in writing or electronically,

of a Plan’s Adverse Benefit Determination on review, setting forth:

Information sufficient to allow the Participant to identify the claim involved (including date of service, the

healthcare provider, the claim amount, if applicable, and a statement describing the availability, upon

request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding

meaning);

A reference to the specific portion(s) of the plan provisions upon which a denial is based;

Specific reason(s) for a denial, including the denial code and its corresponding meaning, and a description

of the Plan’s standard, if any, that was used in denying the claim, and a discussion of the decision;

A description of any additional information necessary for the Participant to perfect the claim and an

explanation of why such information is necessary;

A description of the Plan’s review procedures and the time limits applicable to the procedures. This

description will include information on how to initiate the appeal;

A statement that the Participant is entitled to receive, upon request and free of charge, reasonable access to,

and copies of, all documents, records, and other information relevant to the Participant’s claim for benefits;

The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did

not rely upon their advice (or a statement that the identity of the expert will be provided, upon request);

Any rule, guideline, protocol or similar criterion that was relied upon, considered, or generated in making

the determination will be provided free of charge. If this is not practical, a statement will be included that

such a rule, guideline, protocol or similar criterion was relied upon in making the determination and a copy

will be provided to the Participant, free of charge, upon request;

In the case of denials based upon a medical judgment (such as whether the treatment is medically necessary

or experimental), either an explanation of the scientific or clinical judgment for the determination, applying

the terms of the Plan to the Participant’s medical circumstances, will be provided. If this is not practical, a

statement will be included that such explanation will be provided to the Participant, free of charge, upon

request; and

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The following statement: “You and your Plan may have other voluntary alternative dispute resolution

options, such as mediation. One way to find out what may be available is to contact your local U.S.

Department of Labor Office and your state insurance regulatory agency.”

10.02E Furnishing Documents in the Event of an Adverse Determination

In the case of an Adverse Benefit Determination on review, the Plan Administrator shall provide such access to, and

copies of, documents, records, and other information described in the section relating to “Manner and Content of

Notification of Adverse Benefit Determination on Review” as appropriate.

10.02F Decision on Review

If, for any reason, the Participant does not receive a written response to the appeal within the appropriate time period

set forth above, the Participant may assume that the appeal has been denied. The decision by the Plan Administrator

or other appropriate named fiduciary of the Plan on review will be final, binding and conclusive and will be afforded

the maximum deference permitted by law. All claim review procedures provided for in the Plan must be

exhausted before any legal action is brought.

10.02G External Review Process

A. Scope

1. The Federal external review process does not apply to a denial, reduction, termination, or a failure to

provide payment for a benefit based on a determination that a participant or beneficiary fails to meet the

requirements for eligibility under the terms of a group health plan.

2. The Federal external review process applies only to:

(a) An Adverse Benefit Determination (including a final internal Adverse Benefit Determination) by a

plan or issuer that involves medical judgment (including, but not limited to, those based on the

plan's or issuer's requirements for medical necessity, appropriateness, health care setting, level of

care, or effectiveness of a covered benefit; or its determination that a treatment is experimental or

investigational), as determined by the external reviewer; and

(b) A rescission of coverage (whether or not the rescission has any effect on any particular benefit at

that time).

B. Standard external review

Standard external review is external review that is not considered expedited (as described in paragraph B of this

section).

1. Request for external review. The Plan will allow a claimant to file a request for an external review with the

Plan if the request is filed within four (4) months after the date of receipt of a notice of an Adverse Benefit

Determination or final internal Adverse Benefit Determination. If there is no corresponding date four

months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth

month following the receipt of the notice. For example, if the date of receipt of the notice is October 30,

because there is no February 30, the request must be filed by March 1. If the last filing date would fall on a

Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday,

Sunday, or Federal holiday.

2. Preliminary review. Within five (5) business days following the date of receipt of the external review

request, the Plan will complete a preliminary review of the request to determine whether:

(a) The claimant is or was covered under the Plan at the time the health care item or service was

requested or, in the case of a retrospective review, was covered under the Plan at the time the

health care item or service was provided;

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(b) The Adverse Benefit Determination or the final Adverse Benefit Determination does not relate to

the claimant’s failure to meet the requirements for eligibility under the terms of the Plan (e.g.,

worker classification or similar determination);

(c) The claimant has exhausted the Plan’s internal appeal process unless the claimant is not required to

exhaust the internal appeals process under the interim final regulations; and

(d) The claimant has provided all the information and forms required to process an external review.

Within one (1) business day after completion of the preliminary review, the Plan will issue a notification in

writing to the claimant. If the request is complete but not eligible for external review, such notification will

include the reasons for its ineligibility and contact information for the Employee Benefits Security

Administration (toll-free number 866-444-EBSA (3272)). If the request is not complete, such notification

will describe the information or materials needed to make the request complete and the Plan will allow a

claimant to perfect the request for external review with the four-month filing period or within the 48 hour

period following the receipt of the notification, whichever is later.

3. Referral to Independent Review Organization. The Plan will assign an independent review organization

(IRO) that is accredited by URAC or by a similar nationally-recognized accrediting organization to conduct

the external review. Moreover, the Plan will take action against bias and to ensure independence.

Accordingly, the Plan will contract with (or direct the Claims Processor to contract with, on its behalf) at

least three (3) IROs for assignments under the Plan and rotate claims assignments among them (or

incorporate other independent unbiased method for selection of IROs, such as random selection). In

addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will

support the denial of benefits.

4. Reversal of Plan’s decision. Upon receipt of a notice of a final external review decision reversing the

Adverse Benefit Determination or final internal Adverse Benefit Determination, the Plan will provide

coverage or payment for the claim without delay, regardless of whether the plan intends to seek judicial

review of the external review decision and unless or until there is a judicial decision otherwise.

C. Expedited external review

1. Request for expedited external review. The Plan will allow a claimant to make a request for an expedited

external review with the Plan at the time the claimant receives:

(a) An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical

condition of the claimant for which the timeframe for completion of a standard internal appeal

under the interim final regulations would seriously jeopardize the life or health of the claimant or

would jeopardize the claimant's ability to regain maximum function and the claimant has filed a

request for an expedited internal appeal; or

(b) A final internal Adverse Benefit Determination, if the claimant has a medical condition where the

timeframe for completion of a standard external review would seriously jeopardize the life or

health of the claimant or would jeopardize the claimant's ability to regain maximum function, or if

the final internal Adverse Benefit Determination concerns an admission, availability of care,

continued stay, or health care item or service for which the claimant received emergency services,

but has not been discharged from a facility.

2. Preliminary review. Immediately upon receipt of the request for expedited external review, the Plan will

determine whether the request meets the reviewability requirements set forth in paragraph A.2 above for

standard external review. The Plan will immediately send a notice that meets the requirements set forth in

paragraph A.2 above for standard external review to the claimant of its eligibility determination.

3. Referral to independent review organization. Upon a determination that a request is eligible for external

review following the preliminary review, the Plan will assign an IRO pursuant to the requirements set forth

in paragraph A.3 above for standard review. The Plan will provide or transmit all necessary documents and

information considered in making the Adverse Benefit Determination or final internal Adverse Benefit

Determination to the assigned IRO electronically or by telephone or facsimile or any other available

expeditious method.

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The assigned IRO, to the extent the information or documents are available and the IRO considers them

appropriate, will consider the information or documents described above under the procedures for standard

review. In reaching a decision, the assigned IRO will review the claim de novo and is not bound by any

decisions or conclusions reached during the Plan’s internal claims and appeals process.

4. Notice of final external review decision. The Plan’s (or Claim Processor’s) contract with the assigned IRO

will require the IRO to provide notice of the final external review decision, in accordance with the

requirements set forth in paragraph A.3 above, as expeditiously as the claimant’s medical condition or

circumstances require, but in no event more than 72 hours after the IRO receives the request for an

expedited external review. If the notice is not in writing, within 48 hours after the date of providing that

notice, the assigned IRO will provide written confirmation of the decision to the claimant and the Plan.

10.03 Appointment of Authorized Representative

A Participant is permitted to appoint an authorized representative to act on his or her behalf with respect to a benefit

claim or appeal of a denial. An assignment of benefits by a Participant to a Provider will not constitute appointment

of that Provider as an authorized representative. To appoint such a representative, the Participant must complete a

form which can be obtained from the Plan Administrator or the Third Party Administrator. However, in connection

with a claim involving Urgent Care, the Plan will permit a health care professional with knowledge of the

Participant’s medical condition to act as the Participant’s authorized representative without completion of this form.

In the event a Participant designates an authorized representative, all future communications from the Plan will be

with the representative, rather than the Participant, unless the Participant directs the Plan Administrator, in writing, to

the contrary.

10.04 Physical Examinations

The Plan reserves the right to have a Physician of its own choosing examine any Participant whose condition,

Sickness or Injury is the basis of a claim. All such examinations shall be at the expense of the Plan. This right may

be exercised when and as often as the Plan may reasonably require during the pendency of a claim. The Participant

must comply with this requirement as a necessary condition to coverage.

10.05 Autopsy

The Plan reserves the right to have an autopsy performed upon any deceased Participant whose condition, Sickness,

or Injury is the basis of a claim. This right may be exercised only where not prohibited by law.

10.06 Payment of Benefits

All benefits under this Plan are payable, in U.S. Dollars, to the covered Employee whose Sickness or Injury, or

whose covered Dependent’s Sickness or Injury, is the basis of a claim. In the event of the death or incapacity of a

covered Employee and in the absence of written evidence to this Plan of the qualification of a guardian for his or her

estate, this Plan may, in its sole discretion, make any and all such payments to the individual or institution which, in

the opinion of this Plan, is or was providing the care and support of such Employee.

10.06A Assignments

Benefits for medical expenses covered under this Plan may be assigned by a Participant to the Provider as

consideration in full for services rendered; however, if those benefits are paid directly to the Employee, the Plan

shall be deemed to have fulfilled its obligations with respect to such benefits. The Plan will not be responsible for

determining whether any such assignment is valid. Payment of benefits which have been assigned will be made

directly to the assignee unless a written request not to honor the assignment, signed by the covered Employee and the

assignee, has been received before the proof of loss is submitted.

No Participant shall at any time, either during the time in which he or she is a Participant in the Plan, or following his

or her termination as a Participant, in any manner, have any right to assign his or her right to sue to recover benefits

under the Plan, to enforce rights due under the Plan or to any other causes of action which he or she may have

against the Plan or its fiduciaries.

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A Provider which accepts an assignment of benefits, in accordance with this Plan as consideration in full for services

rendered, is bound by the rules and provisions set forth within the terms of this document.

10.06B Non U.S. Providers

Medical expenses for care, supplies, or services which are rendered by a Provider whose principal place of business

or address for payment is located outside the United States (a “Non U.S. Provider”) are payable under the Plan,

subject to all Plan exclusions, limitations, maximums and other provisions, under the following conditions:

1. Benefits may not be assigned to a Non U.S. Provider;

2. The Participant is responsible for making all payments to Non U.S. Providers, and submitting receipts to the

Plan for reimbursement;

3. Benefit payments will be determined by the Plan based upon the exchange rate in effect on the Incurred

Date;

4. The Non U.S. Provider shall be subject to, and in compliance with, all U.S. and other applicable licensing

requirements; and

5. Claims for benefits must be submitted to the Plan in English.

10.06C Recovery of Payments

Occasionally, benefits are paid more than once, are paid based upon improper billing or a misstatement in a proof of

loss or enrollment information, are not paid according to the Plan’s terms, conditions, limitations or exclusions, or

should otherwise not have been paid by the Plan. As such this Plan may pay benefits that are later found to be greater

than the Maximum Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the

source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such,

whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan

Administrator has the right to recover any such erroneous payment directly from the person or entity who received

such payment and/or from other payers and/or the Plan Participant or dependent on whose behalf such payment was

made.

A Plan Participant, Dependent, Provider, another benefit plan, insurer, or any other person or entity who receives a

payment exceeding the amount of benefits payable under the terms of the Plan or on whose behalf such payment was

made, shall return or refund the amount of such erroneous payment to the Plan within 30 days of discovery or

demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous

payment was made or to which it was applied.

The person or entity receiving an erroneous payment may not apply such payment to another expense. The Plan

Administrator shall have the sole discretion to choose who will repay the Plan for an erroneous payment and whether

such payment shall be reimbursed in a lump sum. When a Plan Participant or other entity does not comply with the

provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of

any claims for benefits by the Plan Participant and to deny or reduce future benefits payable (including payment of

future benefits for other injuries or illnesses) under the Plan by the amount due as reimbursement to the Plan. The

Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other

injuries or illnesses) under any other group benefits plan maintained by the Plan Sponsor. The reductions will equal

the amount of the required reimbursement.

Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been

assigned, in consideration of services rendered, payments and/or rights, agrees to be bound by the terms of this Plan

and agree to submit claims for reimbursement in strict accordance with their State’s health care practice acts, ICD-9

or CPT standards, Medicare guidelines, HCPCS standards, or other standards approved by the Plan Administrator or

insurer. Any payments made on claims for reimbursement not in accordance with the above provisions shall be

repaid to the Plan within 30 days of discovery or demand or incur prejudgment interest of 1.5% per month. If the

Plan must bring an action against a Plan Participant, Provider or other person or entity to enforce the provisions of

this section, then that Plan Participant, Provider or other person or entity agrees to pay the Plan’s attorneys’ fees and

costs, regardless of the action’s outcome.

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Further, Plan Participants and/or their dependents, beneficiaries, estate, heirs, guardian, personal representative, or

assigns (Plan Participants) shall assign or be deemed to have assigned to the Plan their right to recover said payments

made by the Plan, from any other party and/or recovery for which the Plan Participant(s) are entitled, for or in

relation to facility-acquired condition(s), Provider error(s), or damages arising from another party’s act or omission

for which the Plan has not already been refunded.

The Plan reserves the right to deduct from any benefits properly payable under this Plan the amount of any payment

which has been made:

1. In error;

2. Pursuant to a misstatement contained in a proof of loss or a fraudulent act;

3. Pursuant to a misstatement made to obtain coverage under this Plan within two years after the date such

coverage commences;

4. With respect to an ineligible person;

5. In anticipation of obtaining a recovery if a Plan Participant fails to comply with the Plan’s Third Party

Recovery, Subrogation and Reimbursement provisions; or

6. Pursuant to a claim for which benefits are recoverable under any policy or act of law providing for coverage

for occupational Injury or disease to the extent that such benefits are recovered. This provision (6) shall not

be deemed to require the Plan to pay benefits under this Plan in any such instance.

The deduction may be made against any claim for benefits under this Plan by a Plan Participant or by any of his

Covered Dependents if such payment is made with respect to the Plan Participant or any person covered or asserting

coverage as a Dependent of the Plan Participant.

If the Plan seeks to recoup funds from a Provider, due to a claim being made in error, a claim being fraudulent on the

part of the Provider, and/or the claim that is the result of the Provider’s misstatement, said Provider shall, as part of

its assignment to benefits from the Plan, abstain from billing the plan participant for any outstanding amount(s).

10.06D Medicaid Coverage

A Participant’s eligibility for any State Medicaid benefits will not be taken into account in determining or making

any payments for benefits to or on behalf of such Participant. Any such benefit payments will be subject to the

State’s right to reimbursement for benefits it has paid on behalf of the Participant, as required by the State Medicaid

program; and the Plan will honor any Subrogation rights the State may have with respect to benefits which are

payable under the Plan.

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ARTICLE XI

COORDINATION OF BENEFITS

11.01 Benefits Subject to This Provision

This provision shall apply to all benefits provided under any section of this Plan.

11.02 Excess Insurance

If at the time of injury, sickness, disease or disability there is available, or potentially available any Coverage

(including but not limited to Coverage resulting from a judgment at law or settlements), the benefits under this Plan

shall apply only as an excess over such other sources of Coverage.

The Plan’s benefits will be excess to, whenever possible:

a) Any primary payer besides the Plan;

b) Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage,

uninsured or underinsured motorist coverage;

c) Any policy of insurance from any insurance company or guarantor of a third party;

d) Worker’s compensation or other liability insurance company; or

e) Any other source, including but not limited to crime victim restitution funds, any medical, disability or other

benefit payments, and school insurance coverage.

11.03 Vehicle Limitation

When medical payments are available under any vehicle insurance, the Plan shall pay excess benefits only, without

reimbursement for vehicle plan and/or policy deductibles. This Plan shall always be considered secondary to such

plans and/or policies. This applies to all forms of medical payments under vehicle plans and/or policies regardless of

its name, title or classification.

11.04 Allowable Expenses

“Allowable Expenses” shall mean the Usual and Customary charge for any Medically Necessary, Reasonable,

eligible item of expense, at least a portion of which is covered under a plan. When some Other Plan pays first in

accordance with Section 10.06A herein, this Plan’s Allowable Expenses shall consist of the Plan Participant's

responsibility, if any, after the Other Plan has paid but shall in no event exceed the Other Plan’s Allowable

Expenses. When some Other Plan provides benefits in the form of services rather than cash payments, the

reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of

the Plan, shall be deemed to be the benefit. Benefits payable under any Other Plan include the benefits that would

have been payable had claim been duly made therefore.

11.05 “Claim Determination Period”

“Claim Determination Period” shall mean each calendar year.

11.06 Effect on Benefits:

11.06A Application to Benefit Determinations

The plan that pays first according to the rules in the section entitled “Order of Benefit Determination” will pay as if

there were no other plan involved. The secondary and subsequent plans will pay the balance due up to 100% of the

plan's Allowable Expenses. Benefits will be coordinated on the basis of a Claim Determination Period.

When medical payments are available under automobile insurance, this Plan will pay excess benefits only, without

reimbursement for automobile plan deductibles. This Plan will always be considered the secondary carrier

regardless of the individual’s election under personal injury protection (PIP) coverage with the automobile insurance

carrier.

In certain instances, the benefits of the Other Plan will be ignored for the purposes of determining the benefits under

this Plan. This is the case when:

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1. The Other Plan would, according to its rules, determine its benefits after the benefits of this Plan have been

determined; and

2. The rules in the section entitled “Order of Benefit Determination” would require this Plan to determine its

benefits before the Other Plan.

11.06B Order of Benefit Determination

For the purposes of the section entitled “Application to Benefit Determinations,” the rules establishing the order of

benefit determination are:

1. A plan without a coordinating provision will always be the primary plan;

2. The benefits of a plan which covers the person on whose expenses claim is based, other than as a

dependent, shall be determined before the benefits of a plan which covers such person as a dependent;

3. If the person for whom claim is made is a dependent child covered under both parents’ plans, the plan

covering the parent whose birthday (month and day of birth, not year) falls earlier in the year will be

primary, except:

a. When the parents are separated or divorced, and the parent with the custody of the child has not

remarried, the benefits of a plan which covers the child as a dependent of the parent with custody

will be determined before the benefits of a plan which covers the child as a dependent of the parent

without custody; or

b. When the parents are divorced and the parent with custody of the child has remarried, the benefits

of a plan which covers the child as a dependent of the parent with custody shall be determined

before the benefits of a plan which covers that child as a dependent of the stepparent, and the

benefits of a plan which covers that child as a dependent of the stepparent will be determined

before the benefits of a plan which covers that child as a dependent of the parent without custody.

Notwithstanding the above, if there is a court decree which would otherwise establish financial

responsibility for the child’s health care expenses, the benefits of the plan which covers the child as a

dependent of the parent with such financial responsibility shall be determined before the benefits of

any Other Plan which covers the child as a dependent child; and

4. When the rules above do not establish an order of benefit determination, the benefits of a plan which has

covered the person on whose expenses claim is based for the longer period of time shall be determined

before the benefits of a plan which has covered such person the shorter period of time.

11.07 Right to Receive and Release Necessary Information

For the purpose of determining the applicability of and implementing the terms of this provision or any provision of

similar purpose of any Other Plan, this Plan may, without the consent of or notice to any person, release to or obtain

from any insurance company, or other organization or individual, any information with respect to any person, which

the Plan deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the

Plan such information as may be necessary to implement this provision.

11.08 Facility of Payment

Whenever payments which should have been made under this Plan in accordance with this provision have been made

under any Other Plans, the Plan Administrator may, in its sole discretion, pay any organizations making such other

payments any amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts

so paid shall be deemed to be benefits paid under this Plan and, to the extent of such payments, this Plan shall be

fully discharged from liability.

11.09 Right of Recovery

In accordance with section 9.06C, whenever payments have been made by this Plan with respect to Allowable

Expenses in a total amount, at any time, in excess of the maximum amount of payment necessary at that time to

satisfy the intent of this Article, the Plan shall have the right to recover such payments, to the extent of such excess,

from any one or more of the following as this Plan shall determine: any person to or with respect to whom such

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payments were made, or such person’s legal representative, any insurance companies, or any other individuals or

organizations which the Plan determines are responsible for payment of such Allowable Expenses, and any future

benefits payable to the Participant or his or her Dependents. Please see 10.06C above for more details.

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ARTICLE XII

MEDICARE

12.01 Applicable to Active Employees and Their Spouses Ages 65 and Over

An active Employee and his or her spouse (ages 65 and over) may, at the option of such Employee, elect or reject

coverage under this Plan. If such Employee elects coverage under this Plan, the benefits of this Plan shall be

determined before any benefits provided by Medicare. If coverage under this Plan is rejected by such Employee,

benefits listed herein will not be payable even as secondary coverage to Medicare.

12.02 Applicable to All Other Participants Eligible for Medicare Benefits

To the extent required by Federal regulations, this Plan will pay before any Medicare benefits. There are some

circumstances under which Medicare would be required to pay its benefits first. In these cases, benefits under this

Plan would be calculated as secondary payor (as described under the Article entitled “Coordination of Benefits”).

The Participant will be assumed to have full Medicare coverage (that is, both Part A & B) whether or not the

Participant has enrolled for the full coverage. If the Provider accepts assignment with Medicare, covered expenses

will not exceed the Medicare-approved expenses.

12.03 Applicable to Medicare Services Furnished to End Stage Renal Disease (“ESRD”) Plan Participants

Who Are Covered Under This Plan

If any Participant is eligible for Medicare benefits because of ESRD, the benefits of the Plan will be determined

before Medicare benefits for the first 18 months of Medicare entitlement (with respect to charges incurred on or after

February 1, 1991 and before August 5, 1997), and for the first 30 months of Medicare entitlement (with respect to

charges incurred on or after August 5, 1997), unless applicable Federal law provides to the contrary, in which event

the benefits of the Plan will be determined in accordance with such law.

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ARTICLE XIII

THIRD PARTY RECOVERY, SUBROGATION AND REIMBURSEMENT

13.01 Payment Condition

1. The Plan, in its sole discretion, may elect to conditionally advance payment of benefits in those situations where

an injury, sickness, disease or disability is caused in whole or in part by, or results from the acts or omissions of

Plan Participants, and/or their dependents, beneficiaries, estate, heirs, guardian, personal representative, or

assigns (collectively referred to hereinafter in this section as “Plan Participant(s)”) or a third party, where any

party besides the Plan may be responsible for expenses arising from an incident, and/or other funds are

available, including but not limited to no-fault, uninsured motorist, underinsured motorist, medical payment

provisions, third party assets, third party insurance, and/or grantor(s) of a third party (collectively “Coverage”).

2. Plan Participant(s), his or her attorney, and/or legal guardian of a minor or incapacitated individual agrees that

acceptance of the Plan’s conditional payment of medical benefits is constructive notice of these provisions in

their entirety and agrees to maintain one hundred percent (100%) of the Plan’s conditional payment of benefits

or the full extent of payment from any one or combination of first and third party sources in trust, without

disruption except for reimbursement to the Plan or the Plan’s assignee. By accepting benefits the Plan

Participant(s) agrees the Plan shall have an equitable lien on any funds received by the Plan Participant(s) and/or

their attorney from any source and said funds shall be held in trust until such time as the obligations under this

provision are fully satisfied. The Plan Participant(s) agrees to include the Plan’s name as a co-payee on any and

all settlement drafts.

3. In the event a Plan Participant(s) settles, recovers, or is reimbursed by any Coverage, the Plan Participant(s)

agrees to reimburse the Plan for all benefits paid or that will be paid by the Plan on behalf of the Plan

Participant(s). If the Plan Participant(s) fails to reimburse the Plan out of any judgment or settlement received,

the Plan Participant(s) will be responsible for any and all expenses (fees and costs) associated with the Plan’s

attempt to recover such money.

4. If there is more than one party responsible for charges paid by the Plan, or may be responsible for charges paid

by the Plan, the Plan will not be required to select a particular party from whom reimbursement is due.

Furthermore, unallocated settlement funds meant to compensate multiple injured parties of which the Plan

Participant(s) is/are only one or a few, that unallocated settlement fund is considered designated as an

“identifiable” fund from which the plan may seek reimbursement.

13.02 Subrogation

1. As a condition to participating in and receiving benefits under this Plan, the Plan Participant(s) agrees to assign

to the Plan the right to subrogate and pursue any and all claims, causes of action or rights that may arise against

any person, corporation and/or entity and to any Coverage to which the Plan Participant(s) is entitled, regardless

of how classified or characterized, at the Plan’s discretion.

2. If a Plan Participant(s) receives or becomes entitled to receive benefits, an automatic equitable lien attaches in

favor of the Plan to any claim, which any Plan Participant(s) may have against any Coverage and/or party

causing the sickness or injury to the extent of such conditional payment by the Plan plus reasonable costs of

collection.

3. The Plan may, at its discretion, in its own name or in the name of the Plan Participant(s) commence a

proceeding or pursue a claim against any party or Coverage for the recovery of all damages to the full extent of

the value of any such benefits or conditional payments advanced by the Plan.

4. If the Plan Participant(s) fails to file a claim or pursue damages against:

a) The responsible party, its insurer, or any other source on behalf of that party;

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b) Any first party insurance through medical payment coverage, personal injury protection, no-fault

coverage, uninsured or underinsured motorist coverage;



e) Any other source, including but not limited to crime victim restitution funds, any medical, disability or

other benefit payments, and school insurance coverage;

the Plan Participant(s) authorizes the Plan to pursue, sue, compromise and/or settle any such claims in the Plan

Participant(s)’ and/or the Plan’s name and agrees to fully cooperate with the Plan in the prosecution of any such

claims. The Plan Participant(s) assigns all rights to the Plan or its assignee to pursue a claim and the recovery of

all expenses from any and all sources listed above.

13.03 Right of Reimbursement

1. The Plan shall be entitled to recover 100% of the benefits paid, without deduction for attorneys’ fees and costs

or application of the common fund doctrine, make whole doctrine, or any other similar legal theory, without

regard to whether the Plan Participant(s) is fully compensated by his/her recovery from all sources. The Plan

shall have an equitable lien which supersedes all common law or statutory rules, doctrines, and laws of any State

prohibiting assignment of rights which interferes with or compromises in any way the Plan’s equitable lien and

right to reimbursement. The obligation to reimburse the Plan in full exists regardless of how the judgment or

settlement is classified and whether or not the judgment or settlement specifically designates the recovery or a

portion of it as including medical, disability, or other expenses. If the Plan Participant(s)’ recovery is less than

the benefits paid, then the Plan is entitled to be paid all of the recovery achieved.

2. No court costs, experts’ fees, attorneys’ fees, filing fees, or other costs or expenses of litigation may be deducted

from the Plan’s recovery without the prior, expressed written consent of the Plan.

3. The Plan’s right of subrogation and reimbursement will not be reduced or affected as a result of any fault or

claim on the part of the Plan Participant(s), whether under the doctrines of causation, comparative fault or

contributory negligence, or other similar doctrine in law. Accordingly, any lien reduction statutes, which

attempt to apply such laws and reduce a subrogating Plan’s recovery will not be applicable to the Plan and will

not reduce the Plan’s reimbursement rights.

4. These rights of subrogation and reimbursement shall apply without regard to whether any separate written

acknowledgment of these rights is required by the Plan and signed by the Plan Participant(s).

5. This provision shall not limit any other remedies of the Plan provided by law. These rights of subrogation and

reimbursement shall apply without regard to the location of the event that led to or caused the applicable

sickness, injury, disease or disability.

13.04 Excess Insurance

1. If at the time of injury, sickness, disease or disability there is available, or potentially available any Coverage

(including but not limited to Coverage resulting from a judgment at law or settlements), the benefits under this

Plan shall apply only as an excess over such other sources of Coverage, except as otherwise provided for under

the Plan’s Coordination of Benefits section.

The Plan’s benefits shall be excess to:

a) The responsible party, its insurer, or any other source on behalf of that party;

b) Any first party insurance through medical payment coverage, personal injury protection, no-fault

coverage, uninsured or underinsured motorist coverage;



e) Any other source, including but not limited to crime victim restitution funds, any medical, disability or

other benefit payments, and school insurance coverage.

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13.05 Separation of Funds

1. Benefits paid by the Plan, funds recovered by the Plan Participant(s), and funds held in trust over which the Plan

has an equitable lien exist separately from the property and estate of the Plan Participant(s), such that the death

of the Plan Participant(s), or filing of bankruptcy by the Plan Participant(s), will not affect the Plan’s equitable

lien, the funds over which the Plan has a lien, or the Plan’s right to subrogation and reimbursement.

13.06 Wrongful Death

1. In the event that the Plan Participant(s) dies as a result of his or her injuries and a wrongful death or survivor

claim is asserted against a third party or any Coverage, the Plan’s subrogation and reimbursement rights shall

still apply.

13.07 Obligations

1. It is the Plan Participant(s)’ obligation at all times, both prior to and after payment of medical benefits by the

Plan:

a) To cooperate with the Plan, or any representatives of the Plan, in protecting its rights, including

discovery, attending depositions, and/or cooperating in trial to preserve the Plan’s rights;

b) To provide the Plan with pertinent information regarding the sickness, disease, disability, or injury,

including accident reports, settlement information and any other requested additional information;

c) To take such action and execute such documents as the Plan may require to facilitate enforcement of its

subrogation and reimbursement rights;

d) To do nothing to prejudice the Plan’s rights of subrogation and reimbursement;

e) To promptly reimburse the Plan when a recovery through settlement, judgment, award or other

payment is received; and

f) To not settle or release, without the prior consent of the Plan, any claim to the extent that the Plan

Participant may have against any responsible party or Coverage.

2. If the Plan Participant(s) and/or his or her attorney fails to reimburse the Plan for all benefits paid or to be paid,

as a result of said injury or condition, out of any proceeds, judgment or settlement received, the Plan

Participant(s) will be responsible for any and all expenses (whether fees or costs) associated with the Plan’s

attempt to recover such money from the Plan Participant(s).

3. The Plan’s rights to reimbursement and/or subrogation are in no way dependent upon the Plan Participant(s)’

cooperation or adherence to these terms.

13.08 Offset

1. Failure by the Plan Participant(s) and/or his or her attorney to comply with any of these requirements may, at the

Plan’s discretion, result in a forfeiture of payment by the Plan of medical benefits and any funds or payments

due under this Plan on behalf of the Plan Participant(s) may be withheld until the Plan Participant(s) satisfies his

or her obligation.

13.09 Minor Status

1. In the event the Plan Participant(s) is a minor as that term is defined by applicable law, the minor’s parents or

court-appointed guardian shall cooperate in any and all actions by the Plan to seek and obtain requisite court

approval to bind the minor and his or her estate insofar as these subrogation and reimbursement provisions are

concerned.

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2. If the minor’s parents or court-appointed guardian fail to take such action, the Plan shall have no obligation to

advance payment of medical benefits on behalf of the minor. Any court costs or legal fees associated with

obtaining such approval shall be paid by the minor’s parents or court-appointed guardian.

13.10 Language Interpretation

1. The Plan Administrator retains sole, full and final discretionary authority to construe and interpret the language

of this provision, to determine all questions of fact and law arising under this provision, and to administer the

Plan’s subrogation and reimbursement rights. The Plan Administrator may amend the Plan at any time without

notice.

13.11 Severability

1. In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or

illegality shall not affect the remaining sections of this provision and Plan. The section shall be fully severable.

The Plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the

Plan.

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ARTICLE XIV

MISCELLANEOUS PROVISIONS

14.01 Applicable Law

The Plan is funded with employee and/or employer contributions. As such, when applicable, Federal law and

jurisdiction preempt State law and jurisdiction.

14.02 Clerical Error/Delay

Clerical errors made on the records of the Plan and delays in making entries on such records shall not invalidate

coverage nor cause coverage to be in force or to continue in force. Rather, the Effective Dates of coverage shall be

determined solely in accordance with the provisions of this Plan regardless of whether any contributions with respect

to Participants have been made or have failed to be made because of such errors or delays. Upon discovery of any

such error or delay, an equitable adjustment of any such contributions will be made.

14.03 Conformity With Applicable Laws

This Plan shall be deemed to automatically be amended to conform as required by any applicable law, regulation or

the order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not

limited to, stated maximums, exclusions or limitations. In the event that any law, regulation or the order or judgment

of a court of competent jurisdiction causes the Plan Administrator to pay claims which are otherwise limited or

excluded under this Plan, such payments will be considered as being in accordance with the terms of this Plan

Document. It is intended that the Plan will conform to the requirements of any applicable law.

14.04 Fraud

The following actions by any Participant, or a Participant’s knowledge of such actions being taken by another,

constitute fraud and will result in immediate termination of all coverage under this Plan for the entire Family Unit of

which the Participant is a member:

1. Attempting to submit a claim for benefits (which includes attempting to fill a prescription) for a person who

is not a Participant of the Plan;

2. Attempting to file a claim for a Participant for services which were not rendered or Drugs or other items

which were not provided;

3. Providing false or misleading information in connection with enrollment in the Plan; or

4. Providing any false or misleading information to the Plan.

14.05 Headings

The headings used in this Plan Document are used for convenience of reference only. Participants are advised not to

rely on any provision because of the heading.

14.06 No Waiver or Estoppel

No term, condition or provision of this Plan shall be deemed to have been waived, and there shall be no estoppel

against the enforcement of any provision of this Plan, except by written instrument of the party charged with such

waiver or estoppel. No such written waiver shall be deemed a continuing waiver unless specifically stated therein,

and each such waiver shall operate only as to the specific term or condition waived and shall not constitute a waiver

of such term or condition for the future or as to any act other than the one specifically waived.

14.07 Plan Contributions

The Plan Administrator shall, from time to time, evaluate the funding method of the Plan and determine the amount

to be contributed by the Participating Employer and the amount to be contributed (if any) by each Participant.

The Plan Sponsor shall fund the Plan in a manner consistent with the provisions of the Internal Revenue Code, and

such other laws and regulations as shall be applicable to the end that the Plan shall be funded on a lawful and sound

basis; but, to the extent permitted by governing law, the Plan Administrator shall be free to determine the manner and

means of funding the Plan. The amount of the Participant’s contribution (if any) will be determined from time to

time by the Plan Administrator.

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14.08 Right to Receive and Release Information

For the purpose of determining the applicability of and implementing the terms of these benefits, the Plan

Administrator may, without the consent of or notice to any person, release or obtain any information necessary to

determine the acceptability of any applicant or Participant for benefits from this Plan. In so acting, the Plan

Administrator shall be free from any liability that may arise with regard to such action. Any Participant claiming

benefits under this Plan shall furnish to the Plan Administrator such information as may be necessary to implement

this provision.

14.09 Written Notice

Any written notice required under this Plan which, as of the Effective Date, is in conflict with the law of any

governmental body or agency which has jurisdiction over this Plan shall be interpreted to conform to the minimum

requirements of such law.

14.10 Right of Recovery

In accordance with 10.06C, whenever payments have been made by this Plan in a total amount, at any time, in excess

of the maximum amount of benefits payable under this Plan, the Plan shall have the right to recover such payments,

to the extent of such excess, from any one or more of the following as this Plan shall determine: any person to or

with respect to whom such payments were made, or such person’s legal representative, any insurance companies, or

any other individuals or organizations which the Plan determines are responsible for payment of such amount, and

any future benefits payable to the Participant or his or her Dependents. See 10.06C above for full details.

14.11 Statements

All statements made by the Company or by a Plan Participant will, in the absence of fraud, be considered

representations and not warranties, and no statements made for the purpose of obtaining benefits under this document

will be used in any contest to avoid or reduce the benefits provided by the document unless contained in a written

application for benefits and a copy of the instrument containing such representation is or has been furnished to the Plan

Participant.

Any Plan Participant who knowingly and with intent to defraud the Plan, files a statement of claim containing any

materially false information, or conceals for the purpose of misleading, information concerning any material fact,

commits a fraudulent act. The Plan Participant may be subject to prosecution by the United States Department of

Labor. Fraudulently claiming benefits may be punishable by a substantial fine, imprisonment, or both.

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ARTICLE XV

MEDICAL BENEFITS

15.01 Medical Benefits

Subject to the Plan’s provisions, limitations and exclusions, the following are covered major medical benefits:

1. Allergy Services. Charges related to the Treatment of allergies;

2. Ambulance. Transportation by professional ambulance, including approved available air and train

transportation (excluding chartered air flights), to a local Hospital or transfer to the nearest facility having the

capability to treat the condition, if the transportation is connected with an Inpatient Confinement;

3. Ambulatory Surgical Center. Services of an Ambulatory Surgical Center for Medically Necessary care

provided;

4. Anesthesia. Anesthesia, anesthesia supplies, and administration of anesthesia by facility staff;

5. Biofeedback. Biofeedback;

6. Birthing Center. Services of a Birthing Center for Medically Necessary care provided within the scope of its

license;

7. Blood and Plasma. Blood transfusions, plasma and blood derivatives and charges for whole blood not

donated or replaced by a blood bank;

8. Chemotherapy – Oncology Pharmaceutical and Clinical Management Program. This provision

describes a special medical management program designed for certain aspects of care received by cancer

patients who are beneficiaries under the Plan.

Your Plan has entered into an arrangement with Biologics, a company specializing in oncology

management, to assist you and your oncologist during the course of cancer treatment when administered

either in an outpatient setting (e.g., in the physician’s office or other covered outpatient setting) or an

inpatient setting. The program applies to the plan of treatment and the provision of other oncology

pharmaceuticals to be used in connection with your cancer treatment.

In order to initiate these oncology management services, your oncologist should contact your Plan

Administrator to verify Plan benefits. At that time, your oncologist will be asked to contact Biologics

and to provide to your assigned Biologics’ Oncology Nurse Specialist (ONS) a copy of the treatment

plan that your oncologist has prescribed for you. Once the oncologist has contacted Biologics, your

assigned ONS will contact you periodically to provide support, education, and answer any questions you

might have about your disease and your treatment plan. Your assigned Oncology Nurse Specialist will

remain in contact with you and your oncologist for the duration of your chemotherapy treatment plan. In

addition, clinical oncology pharmacists will be available to you and your oncologist on a 24/7 basis by

contacting 1.800.983.1590. You will be encouraged to call this number if you have questions regarding

the cancer drugs being used to treat your cancer, related side effects and other quality of life issues.

If your oncologist determines that oral anti-cancer drugs and/or supportive medications should be taken

in your home following the inpatient or outpatient chemotherapy, your oncologist should contact

Biologics, and those drugs will be sent directly to your home address or another location if you prefer, in

time to meet the medication schedule specified by your oncologist. A clinical oncology pharmacist will

call you to discuss the medications and answer any questions you may have about the specific drugs you

are taking at home.

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Unless your oncologist has entered into an agreement with Biologics to accept other reimbursement

rates, the payment for all drugs used in the treatment of cancer will be limited to the rate of Average

Sales Price plus 10%. Average Sales Price is the price calculated by pharmaceutical manufacturers and

submitted to the Centers for Medicare and Medicaid Services (CMS) on a quarterly basis.

In order to receive benefit payments under the Plan, your oncologist’s chemotherapy plan of treatment

must be received by Biologics and must not be deemed by the Plan Sponsor to be Experimental and/or

Investigational, as defined in the Plan Documents. If any of the drugs prescribed by your oncologist

requires specific pathology results or molecular marker results to validate their use, these results must be

provided to Biologics prior to validation of your treatment regimen.

9. Chiropractic Care. Spinal adjustment and manipulation, x-rays for manipulation and adjustment and other

modalities performed by a Physician or other licensed practitioner, as limited in the Summary of Benefits;

10. Dental. Emergency repair due to Injury to sound natural teeth, if the repair is made within 6 months from the

date of the Injury (unless otherwise required by applicable law);

11. Diagnostic Tests; Examinations. Charges for x-rays, microscopic tests, laboratory tests, esophagoscopy,

gastroscopy, proctosigmoidoscopy, colonoscopy and other diagnostic tests and procedures;

12. Dialysis Treatment – Outpatient. This Section describes the Plan’s Dialysis Benefit Preservation Program

(the “Dialysis Program”). The Dialysis Program shall be the exclusive means for determining the amount of

Plan benefits to be provided to Plan members and for managing cases and claims involving dialysis services

and supplies, regardless of the condition causing the need for dialysis.

A. Reasons for the Dialysis Program. The Dialysis Program has been established for the following

reasons:

(1) the concentration of dialysis providers in the market in which Plan members reside may

allow such providers to exercise control over prices for dialysis-related products and

services,

(2) the potential for discrimination by dialysis providers against the Plan because it is a non-

governmental and non-commercial health plan, which discrimination may lead to

increased prices for dialysis-related products and services charged to Plan members,

(3) evidence of (i) significant inflation of the prices charged to Plan members by dialysis

providers, (ii) the use of revenues from claims paid on behalf of Plan members to

subsidize reduced prices to other types of payers as incentives, and (iii) the specific

targeting of the Plan and other non-governmental and non-commercial plans by the

dialysis providers as profit centers, and

(4) the fiduciary obligation to preserve Plan assets against charges which (i) exceed

reasonable value due to factors not beneficial to Plan members, such as market

concentration and discrimination in charges, and (ii) are used by the dialysis providers for

purposes contrary to the Plan members’ interests, such as subsidies for other plans and

discriminatory profit-taking.

B. Dialysis Program Components. The components of the Dialysis Program are as follows:

(1) Application. The Dialysis Program shall apply to all claims filed by, or on behalf of, Plan

members for reimbursement of products and services provided for purposes of outpatient

dialysis, regardless of the condition causing the need for dialysis (“dialysis-related

claims”).

(2) Claims Affected. The Dialysis Program shall apply to all dialysis-related claims received

by the Plan on or after the original Plan Effective date regardless when the expenses

related to such claim were incurred or when the initial claim for such products or services

was received by the Plan with respect to the Plan member.

(3) Mandated Cost Review. All dialysis-related claims will be subject to cost review by the

Plan Administrator to determine whether the charges indicate the effects of market

concentration or discrimination in charges. In making this determination the Plan

Administrator shall consider factors including:

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i. Market concentration: The Plan Administrator shall consider whether the market

for outpatient dialysis products and services is sufficiently concentrated to permit

providers to exercise control over charges due to limited competition, based on

reasonably available data and authorities. For purposes of this consideration

multiple dialysis facilities under common ownership or control shall be counted

as a single provider.

ii. Discrimination in charges: The Plan Administrator shall consider whether the

claims reflect potential discrimination against the Plan, by comparison of the

charges in such claims against reasonably available data about payments to

outpatient dialysis providers by governmental and commercial plans for the same

or materially comparable goods and services.

(4) In the event that the Plan Administrator’s charge review indicates a reasonable probability

that market concentration and/or discrimination in charges have been a material factors

resulting in an increase of the charges for outpatient dialysis products and/or services for

the dialysis-related claims under review, the Plan Administrator may, in its sole

discretion, determine that there is a reasonable probability that the charges exceed the

reasonable value of the goods and/or services. Based upon such a determination, the Plan

Administrator may subject the claims and all future claims for outpatient dialysis goods

and services from the same provider with respect to the Plan member, to the following

payment limitations, under the following conditions:

i. Where the Plan Administrator deems it appropriate in order to minimize

disruption and administrative burdens for the Plan member, dialysis-related

claims received prior to the cost review determination may, but are not required

to be, paid at the face or otherwise applicable rate.

ii. Where the provider is or has been a participating provider under a Preferred

Provider Organization (PPO) available to the Plan’s members, upon the Plan

Administrator’s determination that payment limitations should be implemented,

the rate payable to such provider shall be subject to the limitations of this

Section.

iii. Maximum Benefit. The maximum Plan benefit payable to dialysis-related claims

subject to the payment limitation shall be the Usual and Reasonable Charge for

covered services and/or supplies, after deduction of all amounts payable by

coinsurance or deductibles.

iv. Usual and Reasonable Charge. With respect to dialysis-related claims, the Plan

Administrator shall determine the Usual and Reasonable Charge based upon the

average payment actually made for reasonably comparable services and/or

supplies to all providers of the same services and/or supplies by all types of

plans in the applicable market during the preceding calendar year, based upon

reasonably available data, adjusted for the national Consumer Price Index

medical care rate of inflation. The Plan Administrator may increase or decrease

the payment based upon factors concerning the nature and severity of the

condition being treated.

v. Additional Information related to Value of Dialysis-Related Services and

Supplies. The Plan member, or where the right to Plan benefits has been

properly assigned to the provider, may provide information with respect to the

reasonable value of the supplies and/or services, for which payment is claimed,

on appeal of the denial of any claim or claims. In the event the Plan

Administrator, in its sole discretion, determines that such information

demonstrates that the payment for the claim or claims did not reflect the

reasonable value, the Plan Administrator shall increase or decrease the payments

(as applicable) to the amount of the reasonable value, as determined by the Plan

Administrator based upon credible information from identified sources. The

Plan Administrator may, but is not required to, review additional information

from third-party sources in making this determination.

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vi. All charges must be billed by a provider in accordance with generally accepted

industry standards.

5. Provider Agreements. Where appropriate, and a willing appropriate provider acceptable

to the Plan member is available, the Plan Administrator may enter into an agreement

establishing the rates payable for outpatient dialysis goods and/or services with the

provider, provided that such agreement must identify this Section of the Plan and clearly

state that such agreement is intended to supersede this Section.

6. Discretion. The Plan Administrator shall have full authority and discretion to interpret,

administer and apply this Section, to the greatest extent permitted by law.

13. Durable Medical Equipment. Charges for rental, up to the purchase price, of Durable Medical Equipment,

including glucose home monitors for insulin-Dependent diabetics. At its option, and with its advance written

approval, the Plan may cover the purchase of such items when it is less costly and more practical than rental.

The Plan does not pay for:

a. Any purchases without its advance written approval;

b. Replacements or repairs; or

c. The rental or purchase of items which do not fully meet the definition of “Durable Medical

Equipment”;

14. Foot Disorders. Surgical treatment of foot disorders, including associated services, performed by a

licensed podiatrist (excluding routine foot care);

15. Glaucoma. Treatment of glaucoma, cataract Surgery and one set of lenses (contacts or frame-type);

16. Gleevec. Gleevec, for treatment of any of the following conditions:

a. CML myeloid blast crisis;

b. CML accelerated phase; or

c. CML in chronic phase after failure of interferon treatment;

Prior authorization is required. In order to obtain such authorization, information from the patients’

Physician indicating the condition being treated must be submitted to the Plan;

17. Hearing Devices. Hearing aids or examinations for the prescription or fitting of hearing aids;

18. Home Health Care. Charges by a Home Health Care Agency:

a. Registered Nurses or Licensed Practical Nurses;

b. Certified home health aides under the direct supervision of a Registered Nurse;

c. Registered therapist performing physical, occupational or Speech Therapy;

d. Physician calls in the office, home, clinic or Outpatient department;

e. Services, drugs and medical supplies which are Medically Necessary for the treatment of the Plan

Participant that would have been provided in the Hospital, but not including Custodial Care; and

f. Rental of Durable Medical Equipment or the purchase of this equipment if economically justified,

whichever is less.

NOTE: Transportation services are not covered under this benefit;

19. Hospice Care. Charges relating to Hospice Care, provided the Plan Participant has a life expectancy of 6

months or less, subject to the maximums, if any, stated in the Summary of Benefits. Covered Hospice expenses

are limited to:

a. Room and Board for Confinement in a Hospice;

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b. Ancillary charges furnished by the Hospice while the patient is confined therein, including rental of

Durable Medical Equipment which is used solely for treating an Injury or Sickness;

c. Medical supplies, drugs and medicines prescribed by the attending Physician, but only to the extent

such items are necessary for pain control and management of the terminal condition;

d. Physician services and nursing care by a Registered Nurse, Licensed Practical Nurse or a Licensed

Vocational Nurse (L.V.N.);

e. Home health aide services;

f. Home care furnished by a Hospital or Home Health Care Agency, under the direction of a Hospice,

including Custodial Care if it is provided during a regular visit by a Registered Nurse, a Licensed

Practical Nurse or a home health aide;

g. Medical social services by licensed or trained social workers, Psychologists or counselors;

h. Nutrition services provided by a licensed dietitian;

i. Respite care; and

j. Bereavement counseling, which is a supportive service provided by the Hospice team to Plan

Participants in the deceased’s Family after the death of the Terminally Ill person, to assist the Plan

Participants in adjusting to the death. Benefits will be payable up to 2 visits per Family per loss if the

following requirements are met:

(1) On the date immediately before his or her death, the Terminally Ill person was in a Hospice

Care Program and a Plan Participant under the Plan; and

(2) Charges for such services are Incurred by the Plan Participants within 6 months of the

Terminally Ill person’s death.

The Hospice Care Program must be renewed in writing by the attending Physician every 30 days. Hospice

Care ceases if the terminal Illness enters remission;

20. Hospital. Charges made by a Hospital for:

a. Inpatient Treatment

(1) Daily Semi-Private Room and Board charges;

(2) Intensive Care Unit (ICU) and Cardiac Care Unit (CCU) Room and Board charges;

(3) General nursing services; and

(4) Medically Necessary services and supplies furnished by the Hospital, other than Room and Board

b. Outpatient Treatment

(1) Emergency room;

(2) Treatment for chronic conditions;

(3) Physical Therapy treatments;

(4) Hemodialysis; and

(5) X-ray, laboratory and linear therapy;

21. Infertility Diagnosis. Charges for the covered diagnostic tests in connection with diagnosing the infertility

condition;

22. Mastectomy. The Federal Women’s Health and Cancer Rights Act, signed into law on October 21, 1998,

contains coverage requirements for breast cancer patients who elect reconstruction in connection with a

Mastectomy. The new Federal law requires group health plans that provide Mastectomy coverage to also

cover breast reconstruction Surgery and prostheses following Mastectomy.

As required by law, you are being provided this notice to inform you about these provisions. The law

mandates that individuals receiving benefits for a Medically Necessary Mastectomy will also receive

coverage for:

a. Reconstruction of the breast on which the Mastectomy has been performed;

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b. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

c. Prostheses and physical complications from all stages of Mastectomy, including lymphedamas;

in a manner determined in consultation with the attending Physician and the patient.

This coverage will be subject to the same annual Deductible and coinsurance provisions that currently apply to

Mastectomy coverage, and will be provided in consultation with you and your attending Physician;

23. Medical Supplies. Dressings, casts, splints, trusses, braces and other Medically Necessary medical supplies,

with the exception of dental braces or corrective shoes, but including syringes for diabetic and allergy

diagnosis, and lancets and chemstrips for diabetics;

24. Newborn Care. Hospital and Physician nursery care for Newborns who are natural children of the Employee

or spouse and properly enrolled in the Plan, as set forth below. Benefits will be provided under the child’s

coverage, and the child’s own Deductible and coinsurance provisions will apply;

a. Hospital routine care for a Newborn during the child’s initial Hospital Confinement at birth; and

b. The following Physician services for well-baby care during the Newborn’s initial Hospital

Confinement at birth:

(1) The initial Newborn examination and a second examination performed prior to discharge

from the Hospital; and

(2) Circumcision.

NOTE: The Plan will cover Hospital and Physician nursery care for an ill Newborn as any other medical

condition, provided the Newborn is properly enrolled in the Plan. These benefits are provided under the

baby’s coverage;

25. Nursing Services. Services of a Registered Nurse or Licensed Practical Nurse;

26. Occupational Therapy. Treatment or services rendered by a registered occupational therapist, under the

direct supervision of a Physician, in a home setting or at a facility or institution whose primary purpose is to

provide medical care for an Illness or Injury, or at a free-standing Outpatient facility;

27. Oral Surgery. Oral Surgery in relation to the bone, including tumors, cysts and growths, not related to the

teeth and extraction of soft tissue impacted teeth by a Physician or Dentist;

28. Pathology Services. Charges for Pathology Services;

29. Physical Therapy. Treatment or services rendered by a physical therapist, under direct supervision of a

Physician, in a home setting or a facility or institution whose primary purpose is to provide medical care for an

Illness or Injury, or at a free-standing duly licensed Outpatient therapy facility;

30. Physician Services. Services of a Physician for Medically Necessary care, including office visits, home visits,

Hospital Inpatient care, Hospital Outpatient visits and exams, clinic care and surgical opinion consultations;

31. Pregnancy Expenses. Dependent Children are eligible for coverage for any expenses in connection with

Pregnancy.

Under the Newborns’ and Mothers’ Health Protection Act of 1996, group health plans and health insurance

issuers generally may not restrict benefits for any Hospital length of stay in connection with childbirth for the

mother or newborn Child to less than 48 hours following a vaginal delivery, or less than 96 hours following a

cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending

Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours

(or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a Provider

obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96

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hours). In no event will an “attending provider” include a plan, hospital, managed care organization, or other

issuer.

Benefits are payable in the same manner as for medical or Surgical care of an Illness, shown in the

“Summary of Benefits” and this section, and subject to the same maximums;

32. Preventive Care. Charges for preventive care services;

33. Private Duty Nursing. Private duty nursing (outpatient only);

34. Prosthetics, Orthotics, Supplies and Surgical Dressings. Prosthetic devices (other than dental) to replace

all or part of an absent body organ or part, including replacement due to natural growth or pathological

change, but not including charges for repair or maintenance. Orthotic devices, but excluding orthopedic

shoes and other supportive devices for the feet;

35. Radiation Therapy. Charges for radiation and dialysis therapy and treatment;

36. Respiration Therapy. Respiration therapy services, when rendered in accordance with a Physician’s

written treatment plan;

37. Second Surgical Opinions. Charges for second surgical opinions;

38. Skilled Nursing Facility. Charges made by a Skilled Nursing Facility or a Convalescent Care Facility, up to

the limits set forth in the Summary of Benefits, in connection with convalescence from an Illness or Injury

(excluding drug addiction, chronic brain syndrome, alcoholism, senility, mental retardation or other Mental or

Nervous Disorders) for which the Plan Participant is confined;

39. Speech Therapy. Speech therapy by a Physician or qualified speech therapist, when needed due to a Sickness

or Injury (other than a functional nervous disorder) or due to surgery performed as the result of a Sickness or

Injury, excluding Speech Therapy services that are educational in any part or due to articulation disorders,

tongue thrust, stuttering, lisping, abnormal speech development, changing an accent, dyslexia, hearing loss

which is not medically documented or similar disorders;

40. Sterilization. Charges related to sterilization procedures;

41. Surgery. Surgical operations and procedures, unless otherwise specifically excluded under the Plan, and

limited as follows:

a. Multiple procedures adding significant time or complexity will be allowed at:

(1) 100% of the full Usual and Customary Fee value for the first or major procedure;

(2) 50% of the Usual and Customary Fee value for the secondary and subsequent procedures;

b. Bilateral procedures which add significant time or complexity, which are provided at the same

operative session, will be allowed at 100% of Usual and Customary Fee value for the major

procedure, and 50% of the Usual and Customary Fee value for the secondary or lesser procedure;

c. Charges made for services rendered by an assistant surgeon will be allowed at 25% of the Usual, and

Customary Fee value for the type of surgery performed;

d. No benefit will be payable for incidental procedures, such as appendectomy during an abdominal

Surgery, performed during a single operative session;

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42. Surgical Treatment of Jaw. Surgical treatment of Diseases, Injuries, fractures and dislocations of the jaw

by a Physician or Dentist;

43. Temporomandibular Joint Disorder. Charges for the diagnosis and treatment of, or in connection with,

temporomandibular joint disorders, myofacial pain dysfunction or orthognathic treatment, which are not in

excess of $500 per Plan Year for Participants over age 16. Participants under age 16 are not subject to a

maximum benefit. If a Physician or Dentist recommends treatment for or in connection with

temporomandibular joint disorders, myofacial pain dysfunction or orthognathic treatment, a

Participant must submit the treatment plan, including x-rays and study models, for

pre-determination of benefits under the Plan. The pre-determination of benefits is required before

any course of treatment is begun. The Plan Administrator will determine if the treatment is a Covered

Expense and will notify the Participant. If treatment is begun before the pre-determination of benefits, no

benefits are payable under the Plan;

44. Tobacco Cessation. Routine screening for tobacco use; counseling for tobacco dependence treatment; all

FDA-approved nicotine replacement products and tobacco cessation medications (over-the-counter and

prescription, Bupropion SR, Varenicline and various forms of nicotine replacement) at least two courses per

Plan Year. Benefits cover at least two quit attempts per year with no lifetime limit on counseling or

pharmacotherapy; and

45. Transplants. Organ or tissue transplants are covered for the following human to human organ or tissue

transplant procedures:

a. Bone marrow;

b. Heart;

c. Lung;

d. Heart and lung;

e. Liver;

f. Pancreas;

g. Kidney; and

h. Cornea.

In addition, the Plan will cover any other transplant that is not Experimental.

Covered expenses will be considered the same as any other Sickness for Employees or Dependents as a

recipient of an organ or tissue transplant. Covered expenses include:

a. Organ or tissue procurement from a cadaver consisting of removing, preserving and transporting

the donated part;

b. Services and supplies furnished by a Provider; and

c. Drug therapy treatment to prevent rejection of the transplanted organ or tissue.

Surgical, storage and transportation costs, including donor medical expenses, directly related to the

procurement of an organ or tissue used in a transplant described herein will be covered. If an organ or

tissue is sold rather than donated, no benefits will be available for the purchase price of such organ or

tissue.

15.02 Psychiatric and Substance Abuse Benefits

15.02A Inpatient Benefits

Subject to the limitations contained in the Summary of Benefits, the Plan will pay covered expenses for:

1. Semi-private hospital Room and Board;

2. Miscellaneous facility charges on days a Room and Board charge is covered;

3. Individual psychotherapy;

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4. Group psychotherapy;

5. Psychological testing;

6. Family counseling; and

7. Convulsive therapy treatment.

The benefits above are also available when receiving treatment during the day only or during the night only at a

day/night Psychiatric Hospital or at a Substance Abuse Treatment Center and/or Rehabilitation Hospital.

15.02B Outpatient Benefits

Subject to the limitations contained in the Summary of Benefits, the Plan will pay covered expenses for:

1. Individual psychotherapy;

2. Group psychotherapy;

3. Psychological testing;

4. Family counseling;

5. Convulsive therapy treatment; and

6. Prescription drugs or medicines for the treatment of mental illness or chemical dependency.

15.03 Exclusions

Some health care services are not covered by the Plan. In addition to the General Exclusions set forth in Article VII,

these include, but are not limited to, any charge for care, supplies, or services, which are:

1. Abortion. Expenses incurred directly or indirectly as the result of an abortion except when the life of the

mother would be threatened if the fetus were carried to term, or when complications arise;

2. Acupuncture. Charges relating directly or indirectly to acupuncture;

3. Consultations. Consultations, charges for failure to keep a scheduled visit, or charges for completion of a

claim form;

4. Cosmetic Surgery. Charges for Cosmetic Surgery;

5. Custodial Care. Custodial Care, domiciliary care or rest cures, or home health care except as specifically

provided herein;

6. Education or Training Program. Services performed by a Physician or other Provider enrolled in an

education or training program when such services are related to the education or training program, except as

specifically provided herein;

7. Eye Refractions. Eye refractions, eyeglasses, contact lenses, or the vision examination for prescribing or

fitting eyeglasses or contact lenses (except for aphakic patients, and soft lenses or sclera shells intended for

use in the treatment of Disease or Injury);

8. Hair Pieces. Wigs, artificial hair pieces, human or artificial hair transplants, or any drug, prescription or

otherwise, used to eliminate baldness;

9. Hypnosis. Expenses related to the use of hypnosis;

10. Impregnation and Infertility Treatment. Following charges related to Impregnation and Infertility

Treatment: artificial insemination, fertility drugs, G.I.F.T. (Gamete Intrafallopian Transfer), impotency

drugs such as Viagra™, in-vitro fertilization, surrogate mother, donor eggs;

11. Obesity. Expenses related to obesity, unless related to morbid obesity (which is the lesser of 100 pounds

over normal weight and twice normal weight);

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12. Oral Surgery. Oral Surgery or dental treatment, except as specifically provided in the Plan;

13. Organ Transplants. Expenses related to donation of a human organ or tissue, except as specifically

provided;

14. Orthopedic Shoes. Orthopedic shoes, unless they are an integral part of a leg brace and the cost is

included in the orthotist’s charge, and other supportive devices for the feet;

15. Osseous Surgery. Charges for osseous Surgery;

16. Personal Convenience Items. Equipment that does not meet the definition of Durable Medical Equipment,

including air conditioners, humidifiers and exercise equipment, whether or not recommended by a

Physician;

17. Pre-existing Condition. Pre-existing Conditions, except as specifically provided in the section entitled

“Special Restrictions for Pre-Existing Conditions”;

18. Radial Keratotomy. Radial keratotomy or other plastic surgeries on the cornea in lieu of eyeglasses;

19. Routine Physical Examinations. Routine or periodic physical examinations, related x-ray and laboratory

expenses, and nutritional supplements, except as provided in the Summary of Benefits;

20. Sex Change Operation. Expenses related to a sex change operation or treatment of sexual dysfunction not

related to organic disease;

21. Travel. Travel, whether or not recommended by a Physician, except as specifically provided herein; and

22. Vitamins. Vitamins.

15.04 Cost Containment

15.04A Pre-Certification Procedures

The Inpatient Utilization Management Service is simple and easy for Participants to use. Whenever a Participant is

advised that Inpatient Hospital care is needed, it is the Participant’s responsibility to call the pre-certification

department at its toll-free number, which is 888-461-0018. The review process will continue, as outlined below,

until the Participant is discharged from the Hospital. Pre-certification is required for Inpatient admission to

skilled nursing facilities, convalescent or rehabilitation facilities unless otherwise stated in this document.

Urgent Care or Emergency Admissions:

If a Participant needs medical care for a condition which could seriously jeopardize his or her life, obtain

such care without delay, and communicate with the Plan as soon as reasonably possible.

If a Participant must be admitted on an Emergency basis, the Participant should follow the Physician’s instructions

carefully and contact the pre-certification department as follows:

1. For Emergency admissions after business hours on Friday, on a weekend or over a holiday weekend, a call

to the pre-certification department must be made within 72 hours after the admission date, but no later than

the first business day following the Emergency admission, by or on behalf of the covered patient; and

2. For Emergency admissions on a weekday, a call to the pre-certification department must be made within 24

hours after the admission date.

The Plan does not require the Participant to obtain approval of a medical service prior to getting treatment for an

urgent care or emergency situation, so there are no “Pre-service Urgent Care Claims” under the Plan. The

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Participant simply follows the Plan’s procedures with respect to any notice which may be required after receipt of

treatment, and files the claim as a Post-service Claim.

Non-emergency Admissions:

For Inpatient Hospital stays that are scheduled in advance, a call to the pre-certification department should be

completed as soon as possible before actual services are rendered. Once the pre-certification call is received, it will

be routed to an appropriate review specialist who will create an on-line patient file. The review specialist will

contact the Participant’s attending Physician to obtain information and to discuss the specifics of the admission

request. An on-line expert system that features state-of-the-art, widely accepted clinical review criteria is used to

effectively guide the review process. If appropriate, alternative care will be explored with the Physician.

If, after assessing procedure necessity, the need for an Inpatient confinement is confirmed, the review specialist will

determine the intensity of management required and will remain in contact with the Physician or Hospital during the

confinement.

If, at any time during the review process, Medical Necessity cannot be validated, the review specialist will refer the

episode to a board-certified Physician advisor who will immediately contact the attending Physician to negotiate an

appropriate treatment plan. At the end of the Hospital confinement, the review specialist is also available to assist

with discharge planning and will work closely with the attending Physician and Hospital to ensure that medically

appropriate arrangements are made.

The pre-certification department hours of operations are 8:00 am to 5:00 pm Monday through Friday. On weekends

and evenings, the Participant can call 888-461-0018, and leave a message.

15.04B Pre-Certification Penalty

The program requires the support and cooperation of each Participant. If a Participant follows the instructions and

procedures, he or she will receive the normal Plan benefits for the services. However, if a Participant fails to notify

pre-certification department of any Inpatient Hospital stay as required in the section entitled “Pre-Certification

Procedures,” allowed charges will be reduced by $500 for Room and Board, Hospital miscellaneous services, and

any other charges related to that confinement which are billed by the Hospital. The Participant will be responsible

for payment of the part of the charge that is not paid by the Plan.

15.04C Alternate Course of Treatment

Certain types of conditions, such as spinal cord Injuries, cancer, AIDS or premature births, may require long-term, or

perhaps lifetime, care. The claims selected will be evaluated as to present course of treatment and alternate care

possibilities.

If the Plan Administrator should determine that an alternate, less expensive, course of treatment is appropriate, and if

the attending Physician agrees to the alternate course of treatment, all Medically Necessary expenses stated in the

treatment plan will be eligible for payment under the Plan, subject to the applicable lifetime benefit set forth in this

Plan, even if these expenses normally would not be eligible for payment under the Plan. In the event the Participant

and the attending Physician select a more expensive course of treatment, coverage under the Plan will be based upon

the charge allowed for the alternate, less expensive, course of treatment.

15.04D Pre-Admission Testing

If a Participant is to be admitted to a Hospital for non-Emergency Surgery or treatment, one set of laboratory tests

and x-ray examinations performed on an outpatient basis within 7 days prior to such Hospital admission will be paid,

with no Deductible, at 100% of the Usual and Customary Fees, provided that the following conditions are met:

1. The tests are related to the performance of the scheduled Surgery or treatment;

2. The tests have been ordered by a Physician after a condition requiring Surgery or treatment has been

diagnosed and Hospital admission has been requested by the Physician and confirmed by the Hospital;

3. The Participant is subsequently admitted to the Hospital, or confinement is cancelled or postponed because

a Hospital bed is unavailable or if, after the tests are reviewed, the Physician determines that the

confinement is unnecessary; and

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4. The tests are performed in the Hospital where the confinement will take place and accepted in lieu of

duplicate tests rendered during confinement.

15.04E Second Surgical Opinion

If a Physician recommends Surgery for a Participant, the Participant may request a second opinion as to whether or

not the Surgery is Medically Necessary.

In addition, the Plan recommends that a second opinion be obtained prior to the following Surgeries:

1. Adenoidectomy;

2. Bunionectomy;

3. Cataract removal;

4. Coronary Bypass;

5. Cholecystectomy (removal of gallbladder);

6. Dilation and curettage;

7. Hammer Toe repair;

8. Hemorrhoidectomy;

9. Herniography;

10. Hysterectomy;

11. Laminectomy (removal of spinal disc);

12. Mastectomy;

13. Meniscectomy (removal of knee cartilage, including arthroscopic approach);

14. Nasal Surgery (repair of deviated nasal septum, bone or cartilage);

15. Prostatectomy (removal of all or part of prostate);

16. Release for entrapment of medial nerve (Carpal Tunnel Syndrome);

17. Tonsillectomy; and

18. Varicose veins (tying off and stripping).

When a second opinion is requested, the Plan will pay 100% of Usual and Customary Fees incurred for that opinion

along with laboratory, x-ray and other Medically Necessary services ordered by the second Physician without

application of the Deductible. Second opinions for cosmetic Surgery, normal obstetrical delivery and Surgeries that

require only local anesthesia are not covered. If the second opinion does not concur with the first, the Plan will pay

for a third opinion as outlined above. The second or third opinion must be given within 90 days of the first.

In all cases where a second opinion is requested, the original recommendation for Surgery must have been obtained

from a Physician licensed in the medical specialty under which the recommended Surgery falls. The Physician

consulted for the second opinion must be licensed in the same medical specialty and may not be a partner of or in

association with the original Physician.

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ARTICLE XVI

DENTAL BENEFITS

Deductible per Individual per calendar year

(applies to Class 2 and 3 Services only) $50

Deductible per Family per calendar year

(applies to Class 2 and 3 Services only) $100

Maximum benefit per calendar year for Class 1, 2 and 3 Services $1,200

Maximum Lifetime benefit for Class 4 Services $1,200 per lifetime

Covered Dental Expenses: Benefits

Class 1 Services (Preventive Care) 100%

Class 2 Services (Repair and Restoration) 80%

Class 3 Services (Major Dental Repair) 60%

Class 4 Services (Orthodontics) 60%

The Deductible amount, if any, which is listed above, is the amount each Participant must pay each calendar year

toward covered expenses. Once the Deductible is satisfied, additional covered expenses will be reimbursed

according to the percentages set forth above, subject to the limitations and exclusions set forth in this Article.

Covered expenses incurred by any Participant and Family Unit in the last three months of any calendar year which

are applied to satisfy the Deductible for that calendar year may also be used toward satisfaction of the Deductible in

the next calendar year.

16.01 Covered Expenses

The following is a brief description of the types of expenses that will be considered for coverage under the Plan,

subject to the limitations contained in the Summary of Benefits. Charges must be for services and supplies

customarily employed for treatment of the dental condition, and rendered in accordance with ADA accepted

standards of practice. Coverage will be limited to Usual and Customary Fees.

Class 1 Services (Preventive Care)

1. Routine oral examinations and prophylaxis (cleaning, scaling and polishing teeth), but not more than once

each in any period of 6 consecutive months;

2. Periapical x-rays, as required, and bitewing x-rays once in any period of 6 consecutive months;

3. Sealants for Dependent Children but not more than once in any period of 12 consecutive months;

4. Topical application of fluoride for Dependent Children, but not more than once in any period of 6

consecutive months;

5. Space maintainers (not made of precious metals) that replace prematurely lost teeth for Dependent Children

under age 19. No payment will be made for duplicate space maintainers; and

6. Palliative Emergency treatment of an acute condition requiring immediate care.

Class 2 Services (Repair and Restoration)

1. All Medically Necessary x-rays;

2. Full mouth x-rays, but not more than once in any period of 6 consecutive months;

3. Panoramic x-rays, but not more than once in any period of 36 consecutive months;

4. Amalgam, silicate, acrylic, synthetic porcelain and composite filling restorations to restore diseased or

accidentally broken teeth. Gold foil restorations are not eligible;

5. Simple extractions;

6. Endodontics, including pulpotomy, direct pulp capping and root canal treatment;

7. Anesthetic services, except local infiltration or block anesthetics, performed by, or under the direct personal

supervision of, and billed for by a Dentist, other than the operating Dentist or his or her assistant;

8. Periodontal examinations, treatment and surgery; and

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9. Consultations.

Class 3 Services (Major Dental Repair)

Prosthodontic services (initial installation or replacement of bridgework or dentures) will be covered only when a

Participant has been covered continuously for at least 12 months, unless otherwise required by applicable law.

1. Inlays, gold fillings, crowns, and initial installation of full or partial dentures or fixed bridgework to replace

one or more natural teeth;

2. Repair or recementing of crowns, inlays, bridgework or dentures and relining of dentures;

3. Unless otherwise required by applicable law, replacement of an existing denture or fixed bridgework, or the

addition of teeth to an existing partial removable denture or bridgework, to replace one or more natural

teeth:

a. Where the existing denture or bridgework was installed at least five years prior to its replacement

and it cannot be made serviceable; or

b. Where the existing denture is an immediate temporary denture, and necessary replacement by the

permanent denture takes place within 12 months;

4. Periodontal scaling;

5. Oral Surgery;

6. Re-lines;

7. Post and core;

8. Stainless steel crowns; and

9. Veneers, for Dependent Children only.

Class 4 Services (Orthodontics)

1. Preliminary study, including cephalometric radiographs, diagnostic casts and treatment plan;

2. Interceptive, interventive or preventive orthodontic services;

3. Fixed and removable appliance placement, and active treatment per month after the first month; and

4. Extractions in connection with orthodontic services.

16.02 Exclusions and Limitations

The following exclusions and limitations are in addition to those set forth in the Articles entitled “General

Limitations and Exclusions,” and “Summary of Benefits.”

1. Adjustments. Charges for services to alter vertical dimension (work done or appliance used to increase the

distance between nose and chin); to restore or maintain occlusion (work done or appliance used to change

the way the top and bottom teeth meet or mesh); to replace tooth structure lost as a result of abrasion or

attrition; for splinting; or for treatment of disturbances of the temporomandibular joint;

2. Administrative Costs. For administrative costs of completing claim forms or reports or for providing

dental records;

3. After the Termination Date. The Plan will not pay for services or supplies furnished after the date

coverage terminates, even if payments have been predetermined for a course of treatment submitted before

the termination date. However, benefits for covered dental expenses incurred for the following procedures

will be payable as though the coverage had continued in force:

a. A prosthetic device, such as full or partial dentures, if the Dentist took the impression and prepared

the abutment teeth while the patient was a Participant in the Plan, and delivers and installs the

device within two months following termination of coverage;

b. A crown, if the Dentist prepared the tooth for the crown while the patient was a Participant in the

Plan, and installs the crown within two months following termination of coverage; and

c. Root canal therapy if the Dentist opened the tooth while the patient was a Participant in the Plan,

and completes the treatment within two months following termination of coverage;

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4. Broken Appointments. For charges for broken or missed dental appointments;

5. Cosmetic. Charges for cosmetic dental work. This includes, but is not limited to, characterization of

dentures and services to correct congenital or developmental malformations. This exclusion will not apply

to cosmetic work needed as a result of Accidental Injuries, but damage resulting from biting or chewing is

not considered an Accidental Injury. This exclusion also does not apply to covered Orthodontic Treatment;

6. Crowns. For crowns for teeth that are restorable by other means or for the purpose of Periodontal

Splinting;

7. Education. Charges for instruction in oral hygiene, plaque control or diet;

8. Excess Charges. Charges in excess of the Reasonable Charge for the service or supply received or charges

in excess of any maximum payable under this Plan;

9. Experimental. Charges for Experimental dental care, implantology or dental care which is not customarily

used or which does not meet the standards set by the American Dental Association;

10. Government Provided. Charges for dental care paid for or provided by the laws of any government or

treatment given in a government-owned facility, unless the Employee or Dependent is legally required to

pay;

11. Hygiene. For oral hygiene, plaque control programs or dietary instructions;

12. Immediate Relative. Services rendered by a person who is an immediate relative of, or who ordinarily

resides with, the Plan Participant requiring treatment. “Immediate relative” means spouse, child, brother,

sister or parent of the Plan Participant, whether by birth, adoption or marriage;

13. Implants. For implants, including any appliances and/or crowns and the surgical insertion or removal of

implants except, first-time non-cosmetic dental implants;

14. Late Enrollee. Charges for crowns, bridgework, dentures, periodontics and orthodontics incurred during

the first 24 months of coverage for a late enrollee, unless such services and supplies are needed as a result

of Accidental Injury sustained by the Plan Participant. (Damage resulting from biting or chewing is not

considered an Accidental Injury.) “Late enrollee” means a person who enrolls for coverage during an

annual enrollment period because he or she failed to enroll when first eligible for coverage or during a

special enrollment period;

15. Miscellaneous. The Plan does not cover any charge, service or supply which is:

a. For treatment other than by a Dentist or Physician, except:

(1) Cleaning, scaling and application of fluoride performed by a licensed dental hygienist

under the supervision of a Dentist; and

(2) Non-experimental services performed at a dental school under the supervision of a

Dentist, if the school customarily charges patients for its services;

b. For local infiltration anesthetic when billed for separately by a Dentist;

c. For personalization or characterization of dentures or veneers or any cosmetic procedures or

supplies;

d. For oral hygiene or dietary instruction;

e. For a plaque control program (a series of instructions on the care of the teeth);

f. For implants, including any appliances and/or crowns and the surgical insertion or removal of

implants;

g. For periodontal splinting;

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h. For consultations, charges for failure to keep a scheduled visit, or charges for completion of a

claim form;

i. For substances or agents which are administered to minimize fear, or charges for analgesia, unless

the patient is handicapped by cerebral palsy, mental retardation or spastic disorder;

j. For replacement of a lost, missing or stolen prosthetic device;

k. Not equal to accepted standards of dental practice, including charges for services or supplies which

are Experimental;

l. Paid, payable or required to be provided under any no-fault or equivalent automobile insurance

law. Any uninsured motorist will be considered to be self-insured;

m. Charges for missed appointments or completion of claim forms;

n. Covered under the “Medical Benefits” Article of the Plan; and

o. Services performed by a Physician or other Provider enrolled in an education or training program

when such services are related to the education or training program, except as specifically provided

herein;

16. Missing Appliances. Charges for replacement of lost, missing or stolen appliances or prosthetic devices;

17. More Expensive Course of Treatment. In all cases involving covered services in which the Provider and

the Participant select a more expensive course of treatment than is customarily provided by the dental

profession, consistent with sound professional standards of dental practice for the dental condition

concerned, coverage under the Plan will be based upon the charge allowed for the lesser procedure;

18. No Coverage. Services or supplies for which charges are incurred at a time when no coverage is in force

for that person, or for which charges are incurred while coverage is in force, but final delivery is made more

than 3 months after the date coverage for that person terminated;

19. No Legal Obligation. Charges for which the person has no legal obligation to pay, or for which no charge

would be made in the absence of a Treatment Plan;

20. No Listing. For services which are not included in the list of covered dental services;

21. Not Necessary. Charges for unnecessary care, treatment, services or supplies, including replacement at any

time of a bridge or denture which meets or can be made to meet commonly held dental standards of

functional acceptability;

22. Not Recommended. Charges for services or supplies which are not recommended and approved by a

Dentist or Physician;

23. Orthognathic Surgery. For surgery to correct malpositions in the bones of the jaw;

24. Personalization. For expenses for services or supplies that are cosmetic in nature, including charges for

personalization or characterization of dentures;

25. Replacements. Charges for replacement made within five years after the last placement of any prosthetic

appliance, crown, inlay or onlay restoration, or fixed bridge. This exclusion is waived if replacement is

needed because the appliance, crown, inlay, onlay or bridge, while in the oral cavity, is damaged beyond

repair due to Injury sustained by the Plan Participant. (Damage resulting from biting or chewing is not

considered an Accidental Injury;)

26. Self-inflicted. Charges for care, treatment, services and supplies needed as a result of intentionally self-

inflicted Injury or Sickness;

27. Single Provider Care. In the event a Participant transfers from the care of one Provider to that of another

during a course of treatment, or if more than one Provider performs services for one or more dental

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procedures, the Plan shall consider only such expense as would be appropriate had a single Provider

performed the service. An appropriate expense in this case will be the Usual and Customary Fee;

28. Splinting. For crowns, fillings or appliances that are used to connect (splint) teeth, or change or alter the

way the teeth meet, including altering the vertical dimension, restoring the bite (occlusion) or are cosmetic;

and

29. War/Riot. Charges for services or supplies needed as a result of war, declared or undeclared, or any act of

war or act of aggression by any Country; or voluntary participation in a riot.

16.03 Pre-determination of Dental Benefits

If a Participant’s proposed course of treatment reasonably can be expected to involve dental charges of $500 or

more, a description of the procedures to be performed and an estimate of the charges therefore may be filed with the

Plan Administrator or Third Party Administrator prior to the commencement of the course of treatment. However,

approval is not required prior to treatment. Any pre-determination of dental benefits is provided only as a

convenience to the Participant.

If requested, the Plan Administrator or Third Party Administrator will notify the Employee, and the Dentist or

Physician, of the pre-determination based upon such proposed course of treatment. In determining the amount of

benefits available, consideration will be given to alternate procedures, services, supplies and courses of treatment

which may be performed to accomplish the required result. The pre-determination is not a guarantee of payment

or approval of a benefit. After treatment is received, a claim must be filed as a post-service claim, which will

be subject to all applicable Plan provisions.

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ARTICLE XVII

PRESCRIPTION DRUG BENEFITS

Covered Prescription Drug Expenses:

Participating Pharmacy10

Pharmacy Option:


Copayment, per prescription or refill, for formulary name brands11

$25


Over-the-Counter Prilosec, Prevacid, Zegerid OTC and Omeprazole12

$0

Mail Order Option13

:


Copayment, per prescription or refill, for formulary name brands11

$50


Participating pharmacies (“Participating Pharmacies”) have contracted with the Plan to charge Participants reduced

fees for covered Drugs. Signature Scripts is the administrator of the prescription drug plan. Participants will be

issued an identification card to use at the pharmacy at time of purchase. Participants will be held fully responsible

for the consequences of any pharmacy identification card after termination of coverage. No reimbursement will be

made when a Drug is purchased from a non-Participating Pharmacy or when the identification card is not

used.

The Mail Order Option is available for maintenance medications (those that are taken for long periods of time, such

as Drugs sometimes prescribed for heart disease, high blood pressure, asthma, etc.). Because of the volume buying,

Caremark, the mail order pharmacy, is able to offer Participants significant savings on their prescriptions.

The copayment is applied to each charge and is shown on the Summary of Benefits, above. The copayment amount

is not counted toward any out-of-pocket maximums under the Plan.

17.01 Covered Expenses

The following are covered under the Plan:

1. Acne Control and Cosmetic Anti-Aging. Accutane and Retin A;

2. Allergy Sera. Charges for allergy sera;

3. Bee Sting Kits. Charges for EPI PEN and Ana-Kit;

4. Blood and Blood Plasma. Charges for Blood and Blood Plasma;

10

100% payment by Plan after copayment.

11

Also includes cost difference between name brand and generic forms, unless prescription is not manufactured in

generic form or Physician has indicated “dispense as written” or similar indication.

12

Must be accompanied by a written request or prescription from the Physician and presented at the time of

purchase.

13

Prescription orders in excess of one refill must be obtained through the Mail Order Option in order to be eligible

for benefits under the Plan.

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5. Compounded Prescriptions. All compounded prescriptions containing at least one prescription ingredient

in a therapeutic quantity;

6. Contraceptives. Charges for other contraceptives (e.g. implants) and contraceptive devices;

7. Diabetes. Insulins, insulin syringes and needles, diabetic supplies – legend, diabetic supplies –

over-the-counter, and glucose test strips, when prescribed by a Physician;

8. Gleevec. Gleevec, for treatment of any of the following conditions:

a. CML myeloid blast crisis;

b. CML accelerated phase; or

c. CML in chronic phase after failure of interferon treatment;

Prior authorization is required. In order to obtain such authorization, information from the patients’

Physician indicating the condition being treated must be submitted to the Plan.

9. Growth Hormones. Charges for growth hormones;

10. Imitrex Injection. Charges for Imitrex injections (migrane auto-injector);

11. Immunizations. Immunization agents or biological sera;

12. Immunologicals. Charges for Immunologicals (vaccines);

13. Impotency. A charge for impotency medication, including Viagra;

14. Injectables. A charge for injectables;

15. Legend Drugs.

a. Diabetic Supplies

b. Diagnostics; and

c. Pre-natal vitamins;

16. Non-Insulin Syringes/Needles. Charges for non-insulin syringes and needles;

17. Oral Contraceptives. Charges for oral contraceptives;

18. Required by Law. All Drugs prescribed by a Physician that require a prescription either by Federal or

State law, except injectables (other than insulin) and the Drugs excluded below;

19. Smoking Deterrents. A charge for Drugs or aids for smoking cessation, including, but not limited to,

nicotine gum and smoking cessation patches; and

20. Steroids. Anabolic steroids.

17.02 Limitations

The benefits set forth in this Article will be limited to:

1. Dosages.

a. With respect to the Pharmacy Option, any one prescription is limited a 31-day supply; and

b. With respect to the Mail Order Option, any one prescription is limited to a 90-day supply.

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2. Refills.

a. Refills only up to the number of times specified by a Physician; and

b. Refills up to one year from the date of order by a Physician.

17.03 Exclusions

In addition to the General Exclusions set forth in Article VII, the following are not covered by the Plan:

1. Administration. Any charge for the administration of a covered Drug;

2. Anorexiants. Anorexiants (weight-loss drugs);

3. Consumed Where Dispensed. Any Drug or medicine that is consumed or administered at the place where

it is dispensed;

4. Devices. Devices of any type, even though such devices may require a prescription, including, but not

limited to, therapeutic devices, artificial appliances, braces, support garments or any similar device;

5. Excluded Items. Any charge excluded under the Articles entitled “General Limitations and Exclusions,” or

“Summary of Benefits”;

6. Experimental Drugs. Experimental Drugs and medicines, even though a charge is made to the Participant;

7. Fertility Agents. Charges for fertility agents;

8. Institutional Medication. A Drug or medicine that is to be taken by a Participant, in whole or in part,

while confined in an Institution, including any Institution that has a facility for dispensing Drugs and

medicines on its premises;

9. Investigational Use Drugs. A Drug or medicine labeled “Caution – limited by Federal law to

investigational use;”

10. Legend Drugs.

a. Legend drugs with over-the-counter equivalents; and

b. Vitamins;

22. Medical Devices and Supplies. Charges for legend and over-the-counter medical devices and supplies;

23. No Charge. A charge for Drugs which may be properly received without charge under local, State or

Federal programs;

24. Non-Prescription Drug or Medicine. A Drug or medicine that can legally be bought without a

prescription, except for injectable insulin;

25. Over-the-counter Drugs. Charges for over-the-counter drugs;

a. Class V Drugs;

b. Diagnostics;

c. Pre-natal vitamins; and

d. Vitamins;

26. Occupational. Prescriptions necessitated due to an occupational activity or event occurring as a result of

an activity for wage or profit] [which an eligible person is entitled to receive without charge under any

workers’ compensation or similar law];

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27. Rogaine. Charges for Rogaine (topical minoxidil); and

28. Vitamins. Vitamins, except pre-natal vitamins.

ARTICLE XVIII

HIPAA PRIVACY

Commitment to Protecting Health Information

The Plan will comply with the Standards for Privacy of Individually Identifiable Health Information (i.e., the

“Privacy Rule”) set forth by the U.S. Department of Health and Human Services (“HHS”) pursuant to the Health

Insurance Portability and Accountability Act (“HIPAA”). Such standards control the dissemination of “protected

health information” (“PHI”) of Plan Participants. Privacy standards will be implemented and enforced in the offices

of the Employer and Plan Sponsor and any other entity that may assist in the operation of the Plan.

The Plan is required by law to take reasonable steps to ensure the privacy of the Plan Participant’s PHI, and inform

him/her about:

1. The Plan’s disclosures and uses of PHI;

2. The Plan Participant’s privacy rights with respect to his/her PHI;

3. The Plan’s duties with respect to his/her PHI;

4. The Plan Participant’s right to file a complaint with the Plan and with the Secretary of HHS; and

5. The person or office to contact for further information about the Plan’s privacy practices.

Within this provision capitalized terms may be used, but not otherwise defined. These terms shall have the same

meaning as those terms set forth in 45 CFR Sections 160.103 and 164.501. Any HIPAA regulation modifications

altering a defined HIPAA term or regulatory citation shall be deemed incorporated into this provision.

How Health Information May be Used and Disclosed

In general, the Privacy Rules permit the Plan to use and disclose an individual’s PHI, without obtaining

authorization, only if the use or disclosure is:

1. To carry out Payment of benefits;

2. For Health Care Operations;

3. For Treatment purposes; or

4. If the use or disclosure falls within one of the limited circumstances described in the rules (e.g., the

disclosure is required by law or for public health activities).

Disclosure of PHI to the Plan Sponsor for Plan Administration Purposes

In order that the Plan Sponsor may receive and use PHI for plan administration purposes, the Plan Sponsor agrees to:

1. Not use or further disclose PHI other than as permitted or required by the Plan documents or as required by

law (as defined in the privacy standards);

2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from

the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such

PHI;

3. Establish safeguards for information, including security systems for data processing and storage;

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4. Maintain the confidentiality of all PHI, unless an individual gives specific consent or authorization to

disclose such data or unless the data is used for health care payment or Plan operations;

5. Receive PHI, in the absence of an individual’s express authorization, only to carry out Plan administration

functions;

6. Not use or disclose PHI for employment-related actions and decisions or in connection with any other

benefit or employee benefit plan of the Plan Sponsor, except pursuant to an authorization which meets the

requirements of the privacy standards;

7. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of

which the Plan Sponsor becomes aware;

8. Make available PHI in accordance with section 164.524 of the privacy standards (45 CFR 164.524);

9. Make available PHI for amendment and incorporate any amendments to PHI in accordance with section

164.526 of the privacy standards (45 CFR 164.526);

10. Make available the information required to provide an accounting of disclosures in accordance with section

164.528 of the privacy standards (45 CFR 164.528);

11. Make its internal practices, books and records relating to the use and disclosure of PHI received from the

Plan available to the Secretary of the U.S. Department of Health and Human Services (“HHS”), or any

other officer or employee of HHS to whom the authority involved has been delegated, for purposes of

determining compliance by the Plan with part 164, subpart E, of the privacy standards (45 CFR 164.500 et

seq);

12. Report to the Plan any inconsistent uses or disclosures of PHI of which the Plan Sponsor becomes aware;

13. Train employees in privacy protection requirements and appoint a privacy compliance coordinator

responsible for such protections;

14. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form

and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made,

except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes

that make the return or destruction of the PHI infeasible; and

15. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in section

164.504(f)(2)(iii) of the privacy standards (45 CFR 164.504(f)(2)(iii)), is established as follows:

(a) The following employees, or classes of employees, or other persons under control of the Plan

Sponsor, shall be given access to the PHI to be disclosed:

(i) Privacy Officer: The access to and use of PHI by the individuals described above shall

be restricted to the plan administration functions that the Plan Sponsor performs for the

Plan.

(b) In the event any of the individuals described in above do not comply with the provisions of the

Plan documents relating to use and disclosure of PHI, the Plan Administrator shall impose

reasonable sanctions as necessary, in its discretion, to ensure that no further non-compliance

occurs. The Plan Administrator will promptly report such violation or non-compliance to the Plan,

and will cooperate with the Plan to correct violation or non-compliance to impose appropriate

disciplinary action or sanctions. Such sanctions shall be imposed progressively (for example, an

oral warning, a written warning, time off without pay and termination), if appropriate, and shall be

imposed so that they are commensurate with the severity of the violation.

Disclosure of Summary Health Information to the Plan Sponsor

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The Plan may disclose PHI to the Plan Sponsor of the group health plan for purposes of plan administration or

pursuant to an authorization request signed by the Plan Participant. The Plan may use or disclose “summary health

information” to the Plan Sponsor for obtaining premium bids or modifying, amending, or terminating the group

health plan.

Disclosure of Certain Enrollment Information to the Plan Sponsor

Pursuant to section 164.504(f)(1)(iii) of the privacy standards (45 CFR 164.504(f)(1)(iii)), the Plan may disclose to

the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has un-enrolled

from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Sponsor.

Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage

The Plan Sponsor may hereby authorize and direct the Plan, through the Plan Administrator or the third party

administrator, to disclose PHI to stop-loss carriers, excess loss carriers or managing general underwriters (“MGUs”)

for underwriting and other purposes in order to obtain and maintain stop-loss or excess loss coverage related to

benefit claims under the Plan. Such disclosures shall be made in accordance with the privacy standards.

Other Disclosures and Uses of PHI:

Primary Uses and Disclosures of PHI

1. Treatment, Payment and Health Care Operations: The Plan has the right to use and disclose a Plan

Participant’s PHI for all activities as included within the definitions of Treatment, Payment, and Health

Care Operations and pursuant to the HIPAA Privacy Rule.

2. Business Associates: The Plan contracts with individuals and entities (Business Associates) to perform

various functions on its behalf. In performance of these functions or to provide services, Business

Associates will receive, create, maintain, use, or disclose PHI, but only after the Plan and the Business

Associate agree in writing to contract terms requiring the Business Associate to appropriately safeguard the

Plan Participant’s information.

3. Other Covered Entities: The Plan may disclose PHI to assist health care Providers in connection with their

treatment or payment activities or to assist other covered entities in connection with payment activities and

certain health care operations. For example, the Plan may disclose PHI to a health care Provider when

needed by the Provider to render treatment to a Plan Participant, and the Plan may disclose PHI to another

covered entity to conduct health care operations. The Plan may also disclose or share PHI with other

insurance carriers (such as Medicare, etc.) in order to coordinate benefits, if a Plan Participant has coverage

through another carrier.

Other Possible Uses and Disclosures of PHI

1. Required by Law: The Plan may use or disclose PHI when required by law, provided the use or disclosure

complies with and is limited to the relevant requirements of such law.

2. Public Health and Safety: The Plan may use or disclose PHI when permitted for purposes of public health

activities, including disclosures to:

(a) a public health authority or other appropriate government authority authorized by law

to receive reports of child abuse or neglect;

(b) report reactions to medications or problems with products or devices regulated by the

Federal Food and Drug Administration or other activities related to quality, safety, or

effectiveness of FDA-regulated products or activities;

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(c) locate and notify persons of recalls of products they may be using; and

(d) a person who may have been exposed to a communicable disease or may otherwise be

at risk of contracting or spreading a disease or condition, if authorized by law.

3. The Plan may disclose PHI to a government authority, except for reports of child abuse or neglect permitted

by (5) above, when required or authorized by law, or with the Plan Participant’s agreement, if the Plan

reasonably believes he/she to be a victim of abuse, neglect, or domestic violence. In such case, the Plan will

promptly inform the Plan Participant that such a disclosure has been or will be made unless the Plan

believes that informing him/her would place him/her at risk of serious harm (but only to someone in a

position to help prevent the threat). Disclosure generally may be made to a minor’s parents or other

representatives although there may be circumstances under Federal or State law when the parents or other

representatives may not be given access to the minor’s PHI.

4. Health Oversight Activities: The Plan may disclose PHI to a health oversight agency for oversight activities

authorized by law. This includes civil, administrative or criminal investigations; inspections; claim audits;

licensure or disciplinary actions; and other activities necessary for appropriate oversight of a health care

system, government health care program, and compliance with certain laws.

5. Lawsuits and Disputes: The Plan may disclose PHI when required for judicial or administrative

proceedings. For example, the Plan Participant’s PHI may be disclosed in response to a subpoena,

discovery requests, or other required legal processes when the Plan is given satisfactory assurances that the

requesting party has made a good faith attempt to advise the Plan Participant of the request or to obtain an

order protecting such information, and done in accordance with specified procedural safeguards.

6. Law Enforcement: The Plan may disclose PHI to a law enforcement official when required for law

enforcement purposes concerning identifying or locating a suspect, fugitive, material witness or missing

person. Under certain circumstances, the Plan may disclose the Plan Participant’s PHI in response to a law

enforcement official’s request if he/she is, or are suspected to be, a victim of a crime and if it believes in

good faith that the PHI constitutes evidence of criminal conduct that occurred on the Sponsor’s or Plan’s

premises.

7. Decedents: The Plan may disclose PHI to a coroner, funeral director or medical examiner for the purpose

of identifying a deceased person, determining a cause of death or as necessary to carry out their duties as

authorized by law.

8. Research: The Plan may use or disclose PHI for research, subject to certain limited conditions.

9. To Avert a Serious Threat to Health or Safety: The Plan may disclose PHI in accordance with applicable

law and standards of ethical conduct, if the Plan, in good faith, believes the use or disclosure is necessary to

prevent or lessen a threat to health or safety of a person or to the public.

10. Workers’ Compensation: The Plan may disclose PHI when authorized by and to the extent necessary to

comply with workers’ compensation or other similar programs established by law.

11. Military and National Security: The Plan may disclose PHI to military authorities of armed forces

personnel under certain circumstances. As authorized by law, the Plan may disclose PHI required for

intelligence, counter-intelligence, and other national security activities to authorized Federal officials.

Required Disclosures of PHI

1. Disclosures to Plan Participants: The Plan is required to disclose to a Plan Participant most of the PHI in a

Designated Record Set when the Plan Participant requests access to this information. The Plan will

disclose a Plan Participant’s PHI to an individual who has been assigned as his/her representative and who

has qualified for such designation in accordance with the relevant State law. Before disclosure to an

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individual qualified as a personal representative, the Plan must be given written supporting documentation

establishing the basis of the personal representation.

The Plan may elect not to treat the person as the Plan Participant’s personal representative if it has a

reasonable belief that the Plan Participant has been, or may be, subjected to domestic violence, abuse, or

neglect by such person, it is not in the Plan Participant’s best interest to treat the person as his/her personal

representative, or treating such person as his/her personal representative could endanger the Plan

Participant.

2. Disclosures to the Secretary of the U.S. Dept of Health and Human Services: The Plan is required to

disclose the Plan Participant’s PHI to the Secretary of the U.S. Department of Health and Human Resources

when the Secretary is investigating or determining the Plan’s compliance with the HIPAA Privacy Rule.

Rights to Individuals

The Plan Participant has the following rights regarding PHI about him/her:

1. Request Restrictions: The Plan Participant has the right to request additional restrictions on the use or

disclosure of PHI for treatment, payment, or health care operations. The Plan Participant may request the

Plan restrict disclosures to family members, relatives, friends or other persons identified by him/her who are

involved in his/her care or payment for his/her care. The Plan is not required to agree to these requested

restrictions.

2. Right to Receive Confidential Communication: The Plan Participant has the right to request that he/she

receive communications regarding PHI in a certain manner or at a certain location. The request must be

made in writing and how the Plan Participant would like to be contacted. The Plan will accommodate all

reasonable requests.

3. Copy of this Notice: The Plan Participant is entitled to receive a paper copy of this notice at any time. To

obtain a paper copy, contact the Privacy Compliance Coordinator.

4. Accounting of Disclosures: The Plan Participant has the right to request an accounting of disclosures the

Plan has made of his/her PHI. The request must be made in writing and does not apply to disclosures for

treatment, payment, health care operations, and certain other purposes. The Plan Participant is entitled to

such an accounting for the six (6) years prior to his/her request, though not earlier than April 14, 2003.

Except as provided below, for each disclosure, the accounting will include: (a) the date of the disclosure,

(b) the name of the entity or person who received the PHI and, if known, the address of such entity or

person; (c) a description of the PHI disclosed, (d) a statement of the purpose of the disclosure that

reasonably informs the Plan Participant of the basis of the disclosure, and certain other information. If the

Plan Participant wishes to make a request, please contact the Privacy Compliance Coordinator.

5. Access: The Plan Participant has the right to request the opportunity to look at or get copies of PHI

maintained by the Plan about him/her in certain records maintained by the Plan. If the Plan Participant

requests copies, he/she may be charged a fee to cover the costs of copying, mailing, and other supplies. To

inspect or copy PHI contact the Privacy Compliance Coordinator. In very limited circumstances, the Plan

may deny the Plan Participant’s request. If the Plan denies the request, the Plan Participant may be entitled

to a review of that denial.

6. Amendment: The Plan Participant has the right to request that the Plan change or amend his/her PHI. The

Plan reserves the right to require this request be in writing. Submit the request to the Privacy Compliance

Coordinator. The Plan may deny the Plan Participant’s request in certain cases, including if it is not in

writing or if he/she does not provide a reason for the request.

Questions or Complaints

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If the Plan Participant wants more information about the Plan’s privacy practices, has questions or concerns, or

believes that the Plan may have violated his/her privacy rights, please contact the Plan using the following

information. The Plan Participant may submit a written complaint to the U.S. Department of Health and Human

Services or with the Plan. The Plan will provide the Plan Participant with the address to file his/her complaint with

the U.S. Department of Health and Human Services upon request.

The Plan will not retaliate against the Plan Participant for filing a complaint with the Plan or the U.S. Department of

Health and Human Services.

Contact Information:

Privacy Compliance Coordinator Contact Information:

Perry County



740-432-9224

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ARTICLE XIX

HIPAA SECURITY

Disclosure of Electronic Protected Health Information (“Electronic PHI”) to the Plan Sponsor for Plan

Administration Functions

STANDARDS FOR SECURITY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

(“SECURITY RULE”)

The Security Rule imposes regulations for maintaining the integrity, confidentiality and availability of protected

health information that it creates, receives, maintains, or maintains electronically that is kept in electronic format

(ePHI) as required under the Health Insurance Portability and Accountability Act (HIPAA).

Definitions;

“Electronic Protected Health Information” (ePHI) is defined in Section 160.103 of the Security Standards (45

C.F.R. 160.103) and means individually identifiable health information transmitted or maintained in any electronic

media.

“Security Incidents” is defined within Section 164.304 of the Security Standards (45 C.F.R. 164.304) and means the

attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or

interference with systems operation in an information system.

Plan Sponsor Obligations

To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions (as defined in 45

CFR §164.504(a)), the Plan Sponsor agrees to:

1. Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the

confidentiality, integrity and availability of the Electronic PHI that it creates, receives, maintains, or

transmits on behalf of the Plan.

2. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in 45 CFR §

164.504(f)(2)(iii), is supported by reasonable and appropriate Security Measures.

3. Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides Electronic PHI

created, received, maintained, or transmitted on behalf of the Plan, agrees to implement reasonable and

appropriate report to the Plan any security incident of which it becomes aware.

4. Report to the Plan any security incident of which it becomes aware.

Notification Requirements in the Event of a Breach of Unsecured PHI

The required breach notifications are triggered upon the discovery of a breach of unsecured PHI. A breach is

discovered as of the first day the breach is known, or reasonably should have been known.

When a breach of unsecured PHI is discovered, the Plan will:

1. Notify the individual whose PHI has been, or is reasonably believed to have been, assessed, acquired, used,

or disclosed as a result of the breach, in writing, without unreasonable delay and in no case later than 60

calendar days after discovery of the breach.

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2. Notify the media if the breach affected more than 500 residents of a State or jurisdiction. Notice must be

provided to prominent media outlets serving the State or jurisdiction without unreasonable delay and in no

case later than 60 calendar days after the date the breach was discovered.

3. Notify the HHS Secretary if the breach involves 500 or more individuals, contemporaneously with the notice

to the affected individual and in the manner specified by HHS. If the breach involves less than 500

individuals, an internal log or other documentation of such breaches must be maintained and annually

submitted to HHS within 60 days after the end of each calendar year.

4. When a Business Associate, which provides services for the Plan and comes in contact with PHI in

connection with those services discovers a breach has occurred, that Business Associate will notify the Plan

without unreasonable delay and in no case later than 60 calendar days after discovery of a breach so that the

affected individuals may be notified. To the extent possible, the Business Associate should identify each

individual whose unsecured PHI has been, or is reasonably believed to have been, breached.

Any terms not otherwise defined in this section shall have the meanings set forth in the Security Standards.